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PATHOLOGY  AND  TREATMENT 


OP 


DISEASES  OF  THE  OVARIES 

(Being  the  Hastinos  Essay  for  1873) 


LAWSON  TAIT,  F.R.C.S.,  Edin.  and  Eng., 

Surgeon  to  the  Birmingham  Hospital  for  Women,  and  Consulting  Surgeon  {for  Diseases  of 

Women)  to  the  West  Bromwich  Hospital ;  Fellow  of  the  Royal  Medico- Chirurgical 

Society;  Member  of  the  Surgical  Society  of  Ireland  and  of  the  Medico- 

Chirurgical  Society  of  Edinburgh,  etc.,  etc. 

HONORARY   FELLOW   OF  THE  AMERICAN  GYNECOLOGICAL   SOCIETY. 


iTourtl)  ©bition,  He-roritten  anb  (Sreatlti  (Knlarigeb 


NEW   TOEK 
WILLIAM    WOOD    &    COMPANY 

56-58  Lafayette  Place 
1883 


Copyright 

WILLIAM  WOOD  &  COMPANY 

1883 


TroVs 

Printing  and  BooKniNDiNC  Company 

201-213  East  Tiiiel/t/t  Street 

New  York 


Deae  Br.  MAEIO^   SIMS, 
jj  SDeMcatc 


this  voltbie  to  you  as  a  token  of  the  value  i  place  upon  your 

fbiendship,  and  as  an  acknowledgsient 

that  much  of  the  new  woek  desceibed  in  it  is  the  outcome  of  youk 

ingenuity. 

Yours  Truly, 

LAWSON  TAIT. 


PREFACE  TO  THE  FOURTH  EDITION. 


Since  the  first  edition  of  this  book  appeared  in  1873,  my  experience 
of  the  subjects  it  deals  with  has  greatly  increased,  and  necessarily  the 
present  work  has  grown  in  size. 

I  have  found  reason  to  change  my  opinion  on  some  points,  but  they 
are  of  much  less  importance  than  I  thought  they  would  be  when  I  first 
sat  down  to  write  these  pages.  I  have  seen  far  more  reason  for  ex- 
tending what  I  had  to  say ;  for  the  marvellous  success  which  now  at- 
tends the  efforts  of  those  who  practise  abdominal  surgery  has  fallen 
largely  to  my  lot,  and  therefore  records  of  things  accomplished,  and 
opinions  expressed  upon  them,  will  be  found  in  these  pages,  which, 
eight  years  ago,  were  certainly  beyond  the  limits  of  acceptance.  Since 
then,  however,  great  advances  have  been  made,  but  much  yet  remains 
to  be  done,  and  all  must  rest  upon  the  patience  of  the  workers  and  the 
forbearance  of  their  critics. 

For  many  imperfections  of  my  book  I  have  to  offer  the  apology 
that  I  have  but  scant  leisure  for  research,  and  fear  I  may  not  have 
done  justice,  in  many  instances,  to  the  work  of  others.  My  writing  is 
chiefly  the  outcome  of  my  own  experience,  and  of  necessity  is  freely 
and  unavoidably  scattered  with  the  pronoun  of  the  first  person. 

To  avoid  needless  and  cumbersome  reference  notes,  I  have  given, 
at  the  head  of  each  chapter,  a  list  of  works  which  I  have  consulted  on 
the  subjects  dealt  with. 

LAWSON  TAIT. 
Birmingham,  Octob&r  3.  1883. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/pathologytreatmOOtait 


CONTENTS. 


OHAPTEE  I. 

PAGE 

Anatomy  and  Physiology  of  the  Ovaby  and  Oviduct,       .        .        o        .      1 


CHAPTEE  n. 

Eeboks  op  Development  and  Displacements  of  the  Ovaries  and  Ovi- 
ducts :  Salpingitis,  Hydkosalpinx,  Pyo- salpinx,  H^tmato-salpinx, 
AND  Fallopian  Pkegnancy, =35 

CHAPTEE  III. 

OOPHOKITIS    AND    PeKI-OOPHOKITIS — ClBEHOSIS    OP    THE    OvABY — AbSCESS    OF 

THE  Ovary,       .        .        , ,87 

CHAPTEE  IV. 

Ovarian  Tumoks  and  Conditions  which  Simulate  Them,   ,        «        .        .  131 

CHAPTEE  V. 
Ovariotomy, 232 

CHAPTEE  VI. 
Eecent  Extensions  of  Abdominal  and  Pelvic  Subgeby,     ....  322 

Cliolecystotomy, 335 

Hepatotomy, 338 

The  Treatment  of  Pelvic  Supptiration  by  Abdominal  Section  and 
Drainage, 3J4 

Index, 353 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  Front  View  of  Left  Broad  Ligament,  .,,•,,..  5 

2.  Diagrammatic  Section  of  Broad  Ligament, 6 

3.  Dissection  of  the  Vena  Cava  (Brinton), 8 

4.  Posterior  View  of  Oviduct  and  Parovarium,  .         .        .         .         ,         .13 

5.  Wolffian  Body  and  Ovary  of  Embryo, 13 

6.  Festal  Section  showing  Development  of  Ovary, 15 

7.  Section  of  Foetal  Ovary, 16 

8.  Primitive  Ova, 17 

9.  Germinal  Epithelium, 17 

10.  Follicular  Epithelium, 18 

11.  Epithelial  Nest, 18 

13.  Development  of  Primitive  Ova,      .         •         . 19 

18.  Section  of  Ovary  at  Third  Month,          ....-..,.  19 

14.  Section  of  Ovary  at  Sixth  Month, 20 

15.  Obsolescence  of  Follicles, 23 

16.  Ovary  at  Menopause, 33 

17.  Senile  Ovary, 33 

18.  Tait's  Wedge  Pessary, 44 

19.  Bilateral  Hydrosalpinx, 59 

30.  Occluded  and  Adherent  Fallopian  Tubes,      .         .         ,         ...         .         .60 

31.  Eight  and  Left  Fallopian  Tubes  and  Ovaries, 60 

23.     Fatal  Case  of  Ruptured  Fallopian  Tube, 78 

23.     Posterior  View  of  Same, 78 

34.  Exanthematic  Cirrhosis  of  Ovary, 107 

35.  Microscopic  Section  of  Same,         . 108 

36.  Altered  Epithelium  from  Ovarian  Cysts,        .......  145 

37.  Myxoma  of  Ovary, 153 

38.  Rokitansky's  Tumor  of  the  Ovary, 174 

39.  Tait's  Trocar  for  Paracentesis  Abdominis,    .         .         .         .         .        .         .  203 

30.  Tait's  Modification  of  Koeberle's  Forceps, 258 

31.  Tait's  Trocar  for  Ovariotomy,        ...» 261 

32.  Tait's  Ether  Apparatus, 367 

33.  Tait's  Wire  Clamp, 385 

34.  Tait's  Staffordshire  Knot, 287 

35.  Double-hitch  Knot, 291 

Plate  showing  Resemblance  between  Foetal  Structure  and  Cancerous  Growth  of 

Ovary, 147 


THE   PATHOLOGY   AND   TREATMENT 


OF 


DISEASES    OF    THE    OVARIES. 


CHAPTER    I. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  OVAEY  AND  OVIDUCT. 

An  Extra  Ovary.     Societe  de  biologie.     Paris,  1875.     Dr.  De  Sinety. 

Anat.  microscop.  de  I'oviducte  de  la  Cestude.    Lataste.    Arch,  de  phys.    No.  3.    1876, 

Der  Nebenstock  des  Weibes.     Kobelt.     Heidelberg,  1847. 

Bierstock  und  Ei.     Waldeyek.     Leipsic,  1870. 

Histoire  generale  et  parfciculiere  du  developement  des  corps  organises.    Coste.    Paris, 

1847. 
Homology  of  the  Sexual  Organs.     Morrison  Watson.     Journal  Anatomy  and  Phys- 
iology.    1879. 
Ou  the  Development  of  the  Ova  and  Structure  of  the  Ovary.     FoULis.     Trans.  Roy. 

Soc.  Edin.,  1875  ;  and  Journal  Anat.  and  Physiol.     Vol.  XIII. 
On  the  Formation  of  Ovules,  and  the  Ovary  of  Mammalia  and  Oviparous  Vertebrata, 

O.  Cadiat.     Memotres  de  I'academie  des  sciences,  Feb.  23,  1880. 
Ovaire  pendant  la  grossesse.     De  Sinety.     Archives  generales.     I.     1877. 
Ovaire  sumumeraire.     De  Sinety.     Ann.  de  gynecologie.     Vol.  VII. 
Ovulation  et  menstruation.     De  Sinety.     Ann.  de  gynecologie.     Vol.  VII. 
Phenomena  accompanying  the  Maturation  and  Impregnation  of  the  Ovum.     F.  M. 

Balfour.     Quarterly  Journal  of  Microscopical  Science,  April,  1875. 
Researches  on  the  Ovary  of  the  Foetus  and  New-born  Child.   De  Sinety.    Paris,  1875. 
Recherches  sur  I'ovaire  du  foetus.     De  Sinety.    Archives  de  physiologic.    No.  5.    1875. 
Recherches  sur  les  corps  de  Wolff.     Follin.     Paris,  1850, 
Recherches  sur  les  ovules  et  sur  I'ovaire.   Par  M.  O.  Cadiat.     Academic  des  sciences, 

Feb.,  1880. 
Researches  upon  the   Supra-renal  Bodies  and  the  Ovary.     C.  Creighton.     Joum. 

Anat.  and  Phys.     Vol.  XIII. 
Sachs  :  Text-book  of  Botany.     London,  1875. 
Structure  and  Development  of  the  Vertebrate  Ovary.    By  F.  M.  BxVlpour.     Quarterly 

Journal  of  Microscopic  Science.     No.  LXII.     1878. 
Traite  pratique  des  maladies  de  I'uterus,  des  ovaires  et  des  trompes.  Par  Prof.  Cour- 

ty.     Paris,  1873. 
1 


2  DISEASES   OF  THE   OVARIES. 

Ueber  Accessoiische  Ovarien.  Dii.  Herman  Beigl.  Wiener  medizin.  Wochensch. 
Heft  12.     1877. 

Upon  the  Formation  and  Significance  of  the  Corpus  Luteum  in  the  Ovaiy.  Otto 
Spiegelbekg.     Monatschrift  fiir  Geburtskunde.     18G7. 

Uterus  and  its  Appendages.  Akthur  Farre.  Encyc.  Anat.  and  Physiology.  Supple- 
mentary vol. 

Zur intrauterinen Entwickelung  der  Graaf schen FoUikel.   Dr.  Haussman.  Berlin,  1875. 

Zur  normalen  und  pathologischen  Histologic  des  Graafschen  Blaschens  des  Menschen. 
Slawianski.     Virchow's  Archives.     Band  LI. 


Within  the  last  ten  years  there  has  grown  up  a  taste— per- 
haps I  had  better  say  a  fashion,  lest  it  should  not  prove  perma- 
nent— for  popular  instruction  in  biology,  and  this  tendency  has 
had  results  of  the  best  kind.  Among  others,  it  has  enabled  us 
to  teach  women,  even  girls,  a  great  deal  which  deeply  concerns 
their  welfare,  in  a  way  which  cannot,  or,  at  least,  ought  not  to 
offend  any.  It  inust  ever  be  regarded  as  a  misfortune  that  the 
most  important  functions  of  life,  those  of  reproduction,  and  the 
most  important  relations  of  society,  those  of  marriage,  have 
usually  been  shrouded  in  mystery  and  darkness,  have  been 
wilfully  misrepresented  to  the  inquiring  and  innocent  mind  of 
youth,  and  have  been  left  entirely  for  their  solution  to  the  per- 
sonal speculations  or  experiment  of  each  adolescent. 

Now,  by  simply  telling  the  life-history  of  a  flower,  and  by 
the  gentlest  hint  that  what  is  true  there  is  true  all  through  life 
up  to  its  highest  developments,  we  may  convey  all  the  instruc- 
tion that  is  needed,  and  all  that  is  demanded  in  the  interests  of 
humanity.  Teach  a  child  the  functions  of  the  anther,  the  stig-" 
ma,  the  pollen,  the  ovary,  and  the  seed-capsule  ;  let  him  or  her 
see  the  conjugation  of  the  spirogyi-a,  and  the  child  will  be  armed 
with  a  knowledge  which  will  do  much  to  prevent  mischief  both 
moral  and  physical. 

Between  the  simple  mass  of  protoplasm  enclosed  in  a  struc- 
tureless capsule  of  cellulose,  Avhich  forms  the  ovum  of  the  alga, 
up  to  the  complex  ovum  of  the  mammal,  with  its  vascular  folli- 
cle, there  is  a  marvellous  difference  in  elaboration  of  detail,  but 
no  difference  in  principle.  The  cellulose  capsule  is  ovary  and 
uterus  in  one.  and  tlie  conjugating  Inids  are  at  once  vagina  and 
oviduct ;  and  from  this  simplicity  the  complexity  arises  only 
from  specialization  of  structure,  and  not  from,  the  introduction 
of  anything  new  in  principle. 

In  the  ahjcB,  and  in  many  other  instances  even  in  animal 
life,  as  the  aphides,  we  have  two  principles  of  reproduction,  or 
rather  of  continuation  :  the  first  is  the  production  of  the  zoo- 
.spore  (swarm-spore),  which  is  effected  without  the  conjunction 
of  two  cells,  and  of  whicli  we  have  the  solitary  trace,  in  mam- 


ANATOMY    AXD    PIIYSrOLOGY    OF   THE    OVAKY.  3 

mals,  of  the  so-called  dermoid  tumor  of  the  ovary  ;  the  second 
method  is  the  formation  of  the  zygospo?-e  (resting-spore)  by  the 
conjunction  of  two  elements,  male  (pollen-grain,  antherozoid, 
or  spermatozoid)  and  female  (ovule,  oospore,  germ-cell,  germinal 
vesicle),  and  with  that  process  alone  the  human  ovary  has  to  do 
in  its  complete  function.  It  must  not  be  forgotten,  however, 
that  the  zoospore  and  the  female  part  of  the  zygospore  are 
essentially  the  same,  that  their  fundamental  functions  are  ex- 
actly the  same,  and  that  the  properties  introduced  by  the  addi- 
tion of  the  sperm-cell  seem  rather  to  be  an  extension  of  those 
already  existing  than  the  creation  of  new  ones.  How  far  this 
analogy  is  extended  to  mammals,  and  especially  to  man,  and 
how  far  it  has  been  curtailed,  is  one  of  the  most  interesting 
questions  of  biology  ;  and  yet  it  is  one  upon  which  we  have  as 
yet  absolutely  no  information. 

Much  unnecessary  confusion  has  been  introduced  into  physio- 
logical writing  and  teaching  by  the  use  of  different  names  for 
the  same  thing  in  different  places.  I  must  here  repeat  the  pro- 
test I  have  frequently  naade,  in  my  lectures  on  biology,  against 
this  practice,  and  my  prediction  that  the  whole  of  our  nomencla- 
ture will  have  to  be  revised  and  this  confusion  reduced  to  order. 
For  example,  why  should  the  male  element  be  called  a  pollen- 
grain  in  the  foxglove,  an  antherozoid  in  an  alga,  and  a  sperma- 
tozoid in  a  moUusk  ?  It  would  be  much  better  to  call  it  an  anther- 
ozoid in  every  instance,  and  still  better  would  it  be  to  drop  our 
old-fashioned  names,  as  Oraafian  follicle,  discus  proligerus,  in 
human  anatomy,  and  give  to  these  structures  names  like  oogo- 
nium, which  would  indicate  their  common  and  real  biological 
significance. 

It  is,  I  fear,  beyond  my  power  to  introduce  such  a  reform, 
yet  in  the  following  pages  I  shall  do  my  best  to  make  such  terms 
more  familiar  to  the  purely  medical  reader. 

It  is  wholly  impossible  to  discuss  the  pathology  and  treat- 
ment of  the  diseases  of  a  structure  like  the  ovary  without  a  full 
understanding. of  its  anatomy  and  physiology;  and  here  we  en- 
ter upon  a  field  vast  and  as  yet  unexhausted.  During  the  last 
twenty  years  perhaps  no  organ  in  the  body  has  been  so  much 
written  about  as  the  ovary;  yet  much  remains  to  be  told,  and 
still  more  to  be  discovered.  To  the  naked  eye  nothing  could 
look  more  uninteresting  and  unimportant  than  a  human  ovary; 
and  yet  upon  it  the  whole  affairs  of  the  world  depend.  As  far 
as  the  individual  owner  of  the  gland  is  concerned — certainly 
for  her  comfort,  and,  if  we  take  with  it  its  appendages,  for  her 
life  as  well,  it  is  the  most  important  organ  in  her  body. 

The  descriptions  given  of  the  rough  anatomy  of  the  organ 


4  DISEASES    OF   THE    OVARIES. 

coincide,  of  course,  closely  enough  ;  but  between  those  of  its  mi- 
nute structure,  its  development,  and  the  processes  carried  on  in 
it,  there  is  considerable  diversity  of  opinion. 

From  1870  to  1S75  I  was  much  engaged  in  these  investiga- 
tions, but  since  then  I  have  been  too  much  engaged  in  practice 
to  follow  them  out  as  fully  as  has  been  done  by  others,  more 
particularly  by  Mr.  F.  M,  Balfour,  the  distinguished  embryolo- 
gist.  With  his  conclusions  and  descriptions,  my  own  work,  so 
far  as  it  has  gone,  most  closely  agrees,  and  therefore,  in  this 
part  of  my  subject.  I  am  greatly  indebted  to  his  papers  for  my 
descriptions  ;  and  while  I  do  not  desire  to  depreciate  the  efforts 
of  other  workers,  I  am  bound  to  say  that  Mr.  Balfour  gives  by 
far  the  most  consistent  and  complete  results. 

The  ovaries  are,  like  most  other  organs  in  the  body,  bilater- 
ally symmetrical ;  that  is,  they  are  similarly  situated,  one  on  each 
side ;  yet  here  the  usual  rule  of  differences  occurs,  for  I  never 
have  seen  two  ovaries  from  the  same  person  exactly  alike  in 
situation,  size,  shape,  or  appearance.  Infinite  variety  in  all  such 
details  are  to  be  observed,  and  any  description  can  only  be  one 
which  is  applicable  to  a  particular  instance,  or  one  of  the  average 
appearances. 

The  size  of  the  ovaries  varies  with  the  different  periods  of 
life;  and,  to  a  less  extent,  so  does  their  distance  from  the  uterus. 
Henning's  table  of  measurements  is  given  below,  the  chiefly 
noteworthy  fact  given  there  being  that  the  ovary  is  largest  in 
the  first  six  weeks  after  parturition.  This  may  have  been  due 
to  some  pathological  condition  in  those  examined  ;  but  in  con- 
nection with  this  it  is  curious  to  note  the  statements  of  horse- 
breeders,  that  a  mare  is  more  readily  impregnated  soon  after  the 
birth  of  a  foal  than  at  any  other  time. 


JleiininrfH  Table  of  the  Size  and  Position,  of  the  Ovaries  at  different  Periods  of  Life  and 
in  various  Soci(d  Co'uditions^  in  Centimetres. 


j  Right. 
(  Left . . 
i  Right. 
■/  Left . . 
j  Right. 
/  Left . . 
Distance  from  the  (Right, 
utenis /  Left . . 

No.  of  cicatrices i  J^^^f*'- 

\  Left . . 


Length  of  the  ovary . 
Dreadth     "  " 


Thickness 


5       5    '    ? 
^        P5    i    P-i 


i.;jto;}.3 

0.2  to  1.4 

0.2toO.C) 

1.0  to  4.0 
1.2to;5.7 

0 

0 


3.8 
3.7 
1.9 
1.5 
l.O 
1.0 
3  4 
3.3 

6 

9 


3.4 
3.8 
1.8 
1.7 
0.9 
0.9 
4.4 
4.5 
14 
13 


3.0 

2.5 

4.4 

2.8 

2.4 

5.5 

1.7 

1.2 

1.3 

1.5 

1.2 

1.4 

1.0 

0.8 

0.8 

0.9 

1.1 

0.9 

4.7 

5.5 

8.0 

4.7 

5.0 

7.0 

21 

22 

8 

21 

21 

8 

1 

1 

5 

i 

1 
§ 

3.5 

3.2 

1.6 

1.7 

0.8 

0.8 

3.8 

4.2 

24  I 

26 


3.5 
3.1 
1.4 
1.4 
0.9 
1.0 
4.0 
4.2 
17 
18 


3.1 
2.5 
1.5 
1.4 
0.8 
O.H 
4.0 
3  7 
15 
24 


2.9 
2.7 
1.1 
1.0 
0.8 
0.9 
4.0 
4.5 
14 
11 


ANATOMY   AND   PHYSIOLOGY   OF   THE   OVAIIY.  5 

The  color  of  the  ovaries  when  perfectly  healthy,  and  in  the 
living  subject,  is  of  a  pinkish,  pearly  hue,  with  here  and  there  a 
hazy  blueness  showing  through  the  tunic  when  a  follicle  is 
either  getting  ready  for  the  discharge  of  its  nucleus  or  is  disap- 
pearing after  having  fulfilled  its  function.  When  a  follicle  is 
either  about  to  burst  or  has  just  burst,  the  site  is  of  a  purftle- 
brown  color.  The  glands  are  oval  in  shape,  and  flattened  from 
before  backward,  the  anterior  surface  being  shorter  and  less 
convex  than  the  posterior,  which  is  more  rounded.  The  outer 
extremity  is  also  rounded  and  bulb-like,  whilst  the  inner  is  some- 
what pointed  and  thinned  off  into  the  broad  ligament.  By  these 
appearances  the  ovary  of  one  side  may  be  recognized  from  the 
other,  if  the  glands  are  healthy.  The  average  weight  of  the 
ovary  is  about  ninety  grains  (Farre). 

The  glands  are  usually  situated  on  a  level  with  the  inlet  of 
the  true  pelvis,  behind  the  Fallopian  tubes  and  round  ligaments. 
Looking  down  upon  the  broad  ligament  from  above,  whilst  it  is 
on  the  stretch,  it  may  be  seen  to  be  formed  of  three  folds,  of 


Fig.  1.— Front  view  of  left  broad  ligament  (after  Richardi:  a,  pavilion  and  fimbria;  6,  bodv  of  the 
tube;  c.  openintf  of  infundibulum  ;  d,  tnbo-ovarian  ligament  (one  of  the  fimbriEe) ;  e,  uterine  end  of  tube  ; 
/',  mcso-salpiiix  ;  g,  ovary;  h,  utero-ovarian  ligament;  t,  fundus  uteri ;  },  round  ligament;  ft,  d,  b,  and  { 
are  the  three  points  of  folding  of  the  broad  ligament. 

which  the  ovaries  occupy  the  posterior,  the  Fallopian  tubes  the 
middle,  and  the  round  ligament  of  the  uterus  the  anterior,  all 
these  structures  being  enveloped  by  folds  of  the  peritoneum  in 
the  same  way  as  is  the  uniform  distribution  of  this .  most  inter- 
esting serous  membrane. 


6 


DISEASES   OF   THE   OVARIES. 


Fig.  '-i.  —  Diagram- 
matic section  of  broad 
ligament :  O,  ovary  ;  B, 
Fallopian  tube,  showini; 
meso-salpinx ;  D,  meso- 
varium. 


Recent  German  writers,  especially  Waldeyer  and  Leopold, 
have  asserted  that  on  the  posterior  surface  of  the  ovary  the 
peritoneal  layer  does  not  exist.  If  so,  it  has  become  incorporated 
with  the  underlying  coat,  the  tunica  albuginea 
of  after-life,  for  it  must  obtain  a  peritoneal  cov- 
ering during  its  developmental  transition.  If  we 
consider  these  facts  for  a  moment,  we  must  con- 
clude that  the  ovary  must  be  enveloped  by  both 
an  anterior  and  posterior  layer,  just  as  a  piece  of 
small  intestine  is,  for  the  mesovarium  always 
has  two  distinct  layers. 

Although  in  the  after-life  of  the  gland  this 
posterior  layer  cannot  be  removed  by  the  scalpel, 
it  is  represented  by  a  layer  of  squamous  epitheli- 
um, which  covers  the  whole  surface  of  the  gland. 
I  have  undertaken  a  special  research  on  this 
subject,  and  find  that  the  posterior  surface, 
when  treated  by  silver  and  other  staining  meth- 
ods, displays  the  same  stomata  and  stigmata  as 
does  the  anterior  surface,  or  indeed  any  other  part  of  the  serous 
surface,  provided  the  delicate  arrangements  are  not  disturbed 
by  clumsy  handling  or  by  chemical  reagents.  In  this  way  I  have 
satisfied  myself  that  the  statement  that  the  posterior  surface  of 
the  ovary  is  destitute  of  peritoneum  is  incorrect. 

The  broad  ligament,  derived  from  the  foldings  already  allu- 
ded to,  is  composed  of  a  process  of  peritoneum  by  which  the 
membrane,  leaving  the  anterior  abdominal  wall  and  the  base  of 
the  bladder,  bends  upward  over  the  fundus  of  the  uterus  and 
the  upper  margin  of  the  Fallopian  tube,  as  far  outward  as  its 
opening.  It  then  dips  down  behind  the  uterus  as  far  as  the  cer- 
vix, and  passes  backward  and  upward  over  the  rectum.  Just  to 
the  outside  of  the  uterus  it  bends  upward,  over,  and  then  down  be- 
hind the  round  ligament  of  the  uterus.  Then  over  the  Fallopian 
tube  it  bends  down  for  a  distance  varying  from  half  an  inch  to 
two  inches,  and  makes  a  very  distinct  meso-salpinx,  at  the  end  of 
which  the  peritoneal  cavit}^  is  opened  into  by  the  infundibulum. 
From  the  lower  margin  of  this,  the  folds  are  continued  in  an  out- 
ward direction  to  the  lateral  parietes.  From  the  posterior  sur- 
face of  the  meso-salpinx  the  posterior  fold  bends  upward  over 
the  anterior  surface  of  the  ovary  in  very  many  instances,  though 
in  others  it  passes  straight  over  the  gland  from  its  upper  margin 
on  to  its  posterior  surface — in  such  cases  no  mesovarium  being 
found. 

In  a  few  exceptions  I  liave  seen  a  crescentic  double  fold  of 
the  posterior  layer  of  the  broad  ligament  pass  down  behind  the 


ATT  ATOMY   AND   PHYSIOLOGY    OF   THE   OVA  II Y.  7 

ovary,  covering  it  like  the  hood  of  a  "Nepenthes "  gland.  In  all 
such  cases  the  women  have  been  sterile,  probably  because  this 
hood  has  prevented  the  application  to  the  ovary  of  the  opening 
of  the  oviduct,  I  have  seen  this  arrangement  give  great  trouble 
in  the  removal  of  small  ovaries. 

From  the  lower  margin  of  the  ovary  the  peritoneum  passes 
downward  to  the  flexure  of  the  recto-uterine  cul-de-sac.  Be- 
tween these  two  folds,  besides  the  tubes  and  the  ovaries,  are  to 
be  found  the  parovarium  on  the  outer  side,  the  utero-ovarian 
ligament  on  the  inner  side,  and  some  irregular  and  faintly 
marked  bundles  of  muscular  fibre,  besides  a  quantity  of  loose 
connective  cellular  tissue. 

Behind  the  right  ovary  lies  the  small  intestine,  and  behind 
the  left  is  the  rectum — a  fact  of  great  importance  in  some  of  the 
pathological  features  of  the  glaijd.  The  ovaries,  the  parovarium 
and  the  Fallopian  tubes,  and  the  vessels  which  supply  them,  lie 
outside  the  peritoneum  really,  and  this  also  is  a  most  important 
fact  in  their  various  diseases.  The  blood-vessels  are  the  utero- 
ovarian  and  ovarian  arteries  and  veins — the  former  derived  from 
the  internal  iliac  vessels,  the  latter  from  the  aorta  and  vena 
cava.  These  latter  vessels  possess  so  much  practical  interest 
that  a  few  words  of  special  description  must  be  given  concerning 
them.  The  arteries,  which  are  the  homologues  of  the  spermatic 
arteries  in  the  male,  arise  from  the  aorta  just  below  the  renal 
branches,  and  pass  obliquely  downward  over  the  psoas  muscle. 
When  they  reach  the  brim  of  the  pelvis  they  turn  inward  and 
forward  (centrally  toward  the  middle  point),  and  run  up  to  the 
ovaries  between  the  folds  of  the  broad  ligament.  They  give  off 
branches  to  the  Fallopian  tube  and  to  the  side  of  the  uterus, 
where  they  anastomose  freely  with  the  branches  of  the  uterine 
arteries  derived  from  the  internal  iliac. 

The  veins  have  an  analogous  distribution.  They  arise  from 
a  venous  plexus  lying  below  the  ovary  and  between  it  and  the 
uterus — the  so-called  bulb  of  the  ovary  (Rouget).  which  has  a 
free  communication  with  the  venous  plexus  at  the  side  of  the 
uterus.  From  this  the  ovarian  veins  have  a  direction  corre- 
sponding with  that  of  their  arteries,  with  this  important  distinc- 
tion, that  the  vein  on  the  right  side  enters  the  inferior  vena  cava 
at  an  acute  angle,  and  on  the  left  side  the  vein  joins  the  renal 
vein  at  a  right  angle. 

It  has  long  been  known  that,  in  the  male,  varicocele  is  much 
more  frequent  on  the  left  side  than  on  the  right,  and  the  expla- 
nation usually  given  of  it  was  the  pressure  which  is,  or  may  be, 
exercised  on  the  left  spermatic  vein  by  a  loaded  rectum.  A 
much  more  exact  explanation  has  resulted  from  a  careful  study 


8 


DISEASES   OF  THE   O VARIES. 


of  these  veins  by  Dr.  J.  H.  Brinton,  of  Philadelphia.  His  deduc- 
tions from  a  Cciref uUy  made  series  of  inquiries  result  in  the  fol- 
lowing : 

1.  That  the  causes  hitherto  assigned  are  insufficient  to  account 
for  the  rare  occurrence  of  varicocele  on  the  right  side. 

2.  That  the  cause  of  this  non-occurrence  is  to  be  referred  to 
the  existence  of  a  very  perfect  valve,  hitherto  unnoticed,  at  the 
termination  of  the  right  spermatic  vein  in  the  vena  cava. 

3.  That  no  such  valve  exists  upon  the  left  side,  at  the  junc- 
tion of  the  spermatic  with  the  renal  vein. 


FiO.  3. Dissection  of  the  vena  cjivn,  emulpent  nnd  ovarian  veins,  sliowinf;  (he  right  ovarian  valve : 

a,  right  ovarian  vein ;  /,  left  ovarian  vein,  witliout  viilve  :  f,  valve  ;  «,  sinus  in  front  of  valve. 


4.  That  a  similar  valve  exists  in  the  analogous  vein  of  the 
female — the  right  ovarian  vein — but  that  there  is  none  on  the 
left  side.    (See  Fig.  3.) 

In  this  I  think  there  is  only  one  error  to  be  noted  :  that  is, 
that  Dr.  Brinton  believes  these  valves  have  not  before  been  no- 


ANATOMY    AND    PHYSIOLOGY    OF   TUP:    OVARY.  9 

ticed.  This  is  not  correct,  for  in  the  third  edition  of  Gray's 
**  Anatomy  "•  (ISG-t),  now  before  me,  it  is  distinctly  stated  that  the 
spermatic  veins  have  valves.  Dr.  Brinton's  merit  consists  rather 
in  showing  that  the  left  vein  has  not  a  valve,  whilst  the  right 
vein  is  provided  with  one. 

The  physiological  fact  we  hav^e  further  to  bear  in  mind  con- 
cerning these  veins  is  that  during  pregnancy  they  increase  enor- 
mously in  size.  These  facts  explain  those  distressing  cases  of 
chronic  ovaritis  and  ovarian  hypera^mia  which  often  start  after 
a  first  confinement,  and  which  are  most  frequently  characterized 
by  the  greatest  suffering  being  in  the  left  ovary,  which  is  always 
enlarged,  and  often  dislocated  down  behind  the  uterus.  These 
cases  are  often  so  intractable  as  to  demand  the  removal  of  the 
ovaries  as  the  only  method  of  permanently  curing  the  patients. 

The  nerves  of  the  ovaries  are  derived  from  the  spermatic 
plexus,  which  in  its  turn  is  derived  from  branches  from  the  re- 
nal and  aortic  plexus.  The  spermatic  nerves  accompany  the 
arteries  to  the  ovaries.  The  Fallopian  tube  has  a  special  branch 
from  one  of  the  uterine  nerves — in  this,  as  in  other  details,  show- 
ing its  method  of  development. 

Dr.  Elischer,  from  investigations  made  in  the  laboratory  for 
embryological  research  of  Prof.  Michalkovics,  in  the  University 
of  Buda-Pesth,  has  satisfied  himself  that  the  nerves  of  the  ovary 
in  mammals  enter  into  the  substance  of  the  organ  in  the  form 
of  medullated  fibres  accompanying  the  looped  and  tortuous  ves- 
sels that  pass  to  the  hilum,  and  run  also  in  the  proper  ligament  of 
the  ovary.  Some  of  the  fasciculi  branch  dichotomously  till  they 
reach  the  follicular  layer  of  the  periphery,  where  they  lose  their 
medullary  sheath,  and  form  loops  around  the  follicles.  Others 
form  a  coarse  plexus  around  the  vessels.  The  more  mature  the 
follicle — that  is  to  say,  the  thicker  the  membrana  granulosa — by 
so  much  the  more  distinctly  can  a  still  somewhat  coarse  plexus 
be  seen  of  tolerably  thick  nerve-fibres  in  the  substance  of  the 
follicular  investment ;  and  from  this  plexus  another  plexus, 
composed  of  more  delicate  fibres,  forming  a  more  elongated  net- 
work, with  numerous  knots  and  varicosities,  can  be  seen  to  arise, 
which  is  applied  to  the  outer  layer  of  the  membrana  granulosa. 
Some  of  the  branches,  he  thinks,  penetrate  the  cells  of  the  mem- 
brana granulosa,  and  run  up  to  the  nucleus.  He  recommends  the 
ovary  of  the  sheep  as  the  object  best  adapted  for  investigation. 

Besides  the  normal  pair  of  ovaries,  accessory  glands — or  per- 
haps, to  speak  more  correctly  of  most  of  the  cases,  separated 
cotyledons — are  met  with.  I  have  not  seen  an  example  of  these, 
and  my  description  is  taken  chiefly  from  the  observations  of 
Herman,  De  Sinety,  and  Beigl. 


10  DISEASES   OF   THE   OVARIES. 

Herman  was,  so  far  as  I  know,  the  first  author  to  notice 
these  interesting  structures,  and  he  describes  the  appearances  in 
the  body  of  a  newly  born  child,  where,  on  the  border  of  one  of 
the  ovaries,  there  was  a  small,  pedunculated  body,  which  proved 
to  be  composed  of  normal  ovarian  tissue,  with  its  follicles  and 
epithelium,  and  having  in  the  centre  an  ovum  with  its  macula 
germinativa.  Dr.  De  Sinety  rather  spoils  his  interesting  obser- 
vation by  suggesting  that  his  case  is  especially  noteworthy  from 
the  probability  that,  if  the  patient  had  lived,  she  would  have 
been  the  subject  of  extra-uterine  i^regnancy.  This  is,  of  course, 
nonsense ;  but  if  she  had  had  both  ovaries  removed  for  disease, 
she  might  have  gone  on  menstruating  if  this  adventitious  struc- 
ture had  been  left ;  and  it  is  possible  that  some  of  the  cases  of 
continued  menstruation,  after  the  removal  of  both  ovaries,  may 
have  their  peculiarity  from  some  such  cause  as  this.  Similarly 
she  might  have  been  the  subject  of  a  third  ovarian  tumor. 

Dr.  Beigl  has  found  similar  structures  eight  times  out  of  three 
hundred  and  fifty  examinations.  They  were  always  situated  at 
the  hilum  of  the  ovary,  at  the  line  of  demarcation  of  the  peri- 
toneum (Waldeyer's  line),  and  they  varied  in  size  from  that  of  a 
hemp-seed  to  that  of  a  small  cherry  (about  8  mm.).  They  gen- 
erally were  set  upon  slender  pedicles,  and  as  many  as  three  were 
found  associated  with  the  same  ovary.  The  subjects  in  which 
they  were  found  were  of  all  ages,  and  the  substance  of  the 
structures  was  true  ovarian  tissue. 

Waldeyer  has  described  one  instance  in  which  as  many  as 
six  of  these  additional  or  accessory  ovaries,  as  he  calls  them, 
were  found ;  but  he  regards  them,  in  some  instances,  as  out- 
growths from  the  ovary  in  the  later  stages  of  its  development. 
He  names  them  '^ISTebeneierstocke,"  which  is  evidently  open  to 
the  objection  that  German  writers  have  already  applied  that 
name  to  the  parovarium.  In  doing  so  they  are,  however,  mis- 
taken, and  I  think  Waldeyer  right  upon  this  point. 

These  accessory  ovaries  show,  by  the  active  growth  of  their 
follicles,  that  they  have  a  distinct  physiological  importance. 

Before  entering  upon  the  difficult  and  complex  subjects  of  the 
development  and  minute  structure  of  the  ovary,  a  few  words 
must  be  said  upon  the  oviduct  and  that  representative  structure, 
the  parovarium,  as  both  of  tliese  have  great  importance  in  the 
diseases  which  truly  belong  to,  or  which  may  simulate  the  true 
diseases  of  the  ovary. 

In  some  of  the  lower  orders  of  fishes  (ganoid)  the  ovaries  shed 
their  ova,  as  soon  as  they  are  ripened,  into  the  peritoneal  cavity, 
whence  they  escape  by  the  abdominal  pores,  to  be  fecundated 


ANATOMY   AND   PHYSIOLOGY   OF   THE   OVARY.  11 

outside  by  the  shed  sperm  of  the  male,  as  in  all  fishes.  In  such 
cases  there  is  free  communication  between  the  peritoneal  cavity 
and  the  outside  water.  In  higher  orders  the  ovaries  are  tubular 
glands,  the  tubes  being  continued,  as  oviducts,  to  the  outside, 
opening  above  and  behind  the  anus.  In  all  other  vertebrata 
there  is  a  break  between  the  oviduct  and  the  ovary ;  and  the 
higher  we  go  in  the  animal  scale,  the  more  complex  does  this 
oviduct  become,  till  we  get  to  the  marsupialia  and  mammalia, 
when  a  part  of  it  is  specialized  for  the  retention  of  the  embryo 
till  it  is  less  or  more  ready  to  maintain  an  independent  existence. 

At  an  early  period  of  embryonic  life  in  the  mammal  the  pri- 
mordial kidneys  (Wolffian  bodies)  are  each  symmetrically  pro- 
vided with  a  duct — the  Wolffian  duct — which  passes  backward 
along  the  outer  side  of  its  corresponding  gland,  and  opens  pos- 
teriorly into  the  sac  of  the  allantois. 

Somewhat  later  another  duct  appears  on  the  anterior  surface 
of  each  Wolffian  body,  but  remains  throughout  its  whole  extent 
distinct  from  this  gland,  and  never  functionally  connected  with 
it.  Traced  backward  from  the  gland  it  soon  comes  in  contact 
with  the  Wolffian  duct,  and  together  they  form  the  genital  cord. 
The  Miillerian  duct  opens  at  its  anterior  extremity  into  the 
pleuro-peritoneal  cavity,  and  posteriorly  into  the  sac  of  the  al- 
lantois. In  the  male  the  Wolffian  ducts  persist,  and  ultimately  ■ 
form  the  vasa  defei'entia,  whilst  the  Miillerian  ducts  atrophy, 
with  the  exception  of  a  small  portion,  which  persists  as  the  vesi- 
cula  prostatica,  or  male  uterus. 

In  all  animals  but  the  didelphous  and  monodelphous  mam- 
mialia,  the  Miillerian  ducts  undergo  no  further  modification  of 
any  great  morphological  importance,  save  in  birds,  where  the 
right  duct  is  atrophied  at  an  early  period  and  the  left  only  is 
developed.  But  in  the  monodelphous  mammalia  the  two  ducts 
become  united  at  a  short  distance  from  their  posterior  openings, 
and  then,  by  the  disappearance  of  the  coalesced  wall,  form  a 
vagina  with  two  uterine  openings;  or,  by  a  further  coalescence, 
form  a  single  vagina  and  a  single  uterus,  into  which  two  Fallo- 
pian tubes  open,  these  tubes  being  the  survivals,  in  the  higher 
mammals,  of  the  two  Miillerian  ducts,  retaining  their  openings 
into  what  was  the  pleuro-peritoneal  cavity  before  its  division  by 
the  diaphragm.  In  some  didelphous  mammalia  the  two  tubes 
remain  separate  throughout  their  length,  giving  two  vaginas, 
two  uteri,  and  two  Fallopian  tubes,  and  instances  of  all  the  vary- 
ing conditions  found  in  antecedent  animals  are  found  occasion- 
ally in  women  as  reversions. 

In  female  mammals  the  Wolffian  ducts  disappear  almost  en- 
tirely in  most  species,  being  permanently  and  constantly  repre- 


12 


DISEASES   OF   THE   OVARIES. 


sented  only  by  the  apparently  functionless  organ  of  Rosenmiiller 
(Figs.  4  and  5).  When  further  survivals  of  them  persist  they 
are  known  as  the  canals  of  Gaertner,  which  in  a  few  mammals, 


Fig.  4  (after  Kobelt). — View  of  oviduct  and  parovarium  from  behind  :  a,  a.  inverted  pyramid  formed 
by  convoluted  tubules  of  parovarium ;  6,  outer  tubules,  fiask-shuped,  and  often  dilated  into  cysts ;  e,  atro- 
phied Wolffiiin  duet,  or  canal  of  Gaertner  (lower  down) ;  /,  terminal  bulb  of  Wolffian  duct,  known  as  orfian 
of  Rosenmiiller:  A,  Fallopian  tube,  or  altered  Miillerian  ducts'  i,  terminal  bulb  of  same,  known  as  the 
hydatid  of  Morgagui  in  the  male. 

as  the  cow  and  the  pig,  retain  a  large  size,  but  serve  no  purpose, 
so  far  as  is  known.  They  commence  above,  lying  in  close  rela- 
tion to  the  organ  of  Rosenmuller  (e,  Fig.  4),  and  run  down  either 

in  the  substance  of  the  ute- 
■v."""-^-..      rus,  or  close  to  it,  between  the 
i  ;''       layers  of  the  broad  ligament. 
•  ■•         They  open  into  the  uro-geni- 
//         tal  sinus  on  either  side  of  the 
//  meatus  urinarius.     In  excep- 

//  tional  cases  they  are  found 

in  women,  and  even  during 
life  their  openings  in  the  posi- 
tion indicated  may  be  clearly 
seen. 

When,  in  the  human  em- 
bryo, the  coalescence  of  the 
two  tubes  has  so  far  ad- 
vanced as  to  form  the  utero- 
vaginal canal,  the  remaining 
part  of  the  tube  is  bent 
sharply  downward  and  out- 
ward, and  thereafter  occu- 
pies its  normal  (nearly)  hori- 
zontal position.  It  leaves  the  uterus  at  the  cornu  (ostium  inter- 
num), at  this  part  of  its  course  through  the  uterine  tissue  being 


Fl<i.  5  (aftci     I  Wulflian  body  and   ovary  of 

pmbr\o  of  the  .sixlh  week;  a.  a.  tubules  of  Wolffian 
body  :  /\  excretory  duct ;  /,  terminal  bulb  (organ  of  Ko- 
FeniiiuUer);  h,  Miillerian  duet;  i.  terminal  bulb  (",  Fig. 
4):  X.  uro-genital  sinus,  into  which  both  ducts  open. 
The  dotted  outline  shows  bent  position  of  Mullcriun 
duct  when  it  has  become  the  Fallopian  lube. 


AIS-ATOMY   AND   PHYSIOLOGY   OF  THE   OVARY.  13 

of  very  narrow  calibre.  From  this  point  it  extends  outward  for 
a  distance  varying  in  the  adult  from  three  to  five  inches,  its 
diameter  increasing  slightly  as  it  leaves  the  uterus,  and  con- 
tracting again  at  the  ostium  abdominale,  where  it  opens  out  into 
the  infundibulum.  It  consists  of  three  coats*  one  derived  from 
the  folding  over  it  of  the  peritoneum,  as  tilready  described.  The 
greater  part  of  its  wall  is  therefore  in  direct  contact  with  the  out- 
side surface  of  the  peritoneum.  The  lesser  portion  of  the  wall 
is  in  contact  with  the  cellular  tissue,  which  occupies  the  space 
between  the  two  folds  of  the  broad  ligament,  at  the  lower  aspect 
of  the  tube  (meso-salpinx)  (Fig.  2).  The  middle  coat  is  muscu- 
lar, and  consists  of  a  faint  layer  of  longitudinal  fibres  externally, 
and  a  much  thicker  layer  of  circular  fibres  internally.  The  lon- 
gitudinal fibres,  according  to  my  own  observations,  disappear 
entirely  about  the  menopause,  or  soon  after.  The  internal  or 
mucous  surface  is  thrown  into  a  series  of  delicate  longitudinal 
folds  by  the  action  of  the  circular  fibres,  an  arrangement  exactly 
similar  to  that  which  obtains  in  the  oesophagus  and  urethra. 
The  mucous  surface  of  the  tube  is  lined  v^ith  ciliated  epithelium, 
the  movements  of  which  are  directed  toward  the  uterus,  and  the 
function  of  which  is  certainly  to  prevent  the  passage  of  sperma- 
tozoa up  the  tube.  If  this  were  not  so,  tubal  pregnancy  would 
be  much  more  common  than  it  is.  The  movement  of  the  cilia 
also  undoubtedly  aids  the  passage  of  the  ovum  down  the  tube, 
and  prevents  its  adhesion  to  the  wall  should  the  ovum  happen 
to  become  occupied  by  spermatozoa.  At  the  ostium  abdominale 
the  tube  expands  trumpet-like,  the  expansion  being  formed  by  a 
series  of  fimbriae,  or  lacinise,  of  two  sizes,  major  and  minor. 
This  infundibulum  (known  also  as  the  morsus  diaboli)  (a,  Fig.  1) 
is  large  enough  to  embrace  about  one-third  of  the  ovary,  and 
seems  to  have  a  curious  tendency  to  enlarge  as  the  ovary  en- 
larges in  diseased  conditions.  The  major  fimbrise  have  the  mi- 
nor fimbrise  arranged  between  them  somewhat  irregularly,  and 
when  a  Graafian  follicle  is  nearly  ready  to  burst,  the  infundibu- 
lum is  said  to  be  applied  over  the  part  of  the  ovary  where  the 
ripe  follicle  is  and  becomes  attached  to  the  surface  by  a  slight 
cellular  adhesion.  If  so,  there  must  be  some  peculiar  and  wholly 
unknown  selective  influence  which  governs  this  adhesion,  but  it 
clearly  is  a  mechanism  not  of  universal  or  constant  accuracy; 
for  I  have  frequently,  during  abdominal  sections,  seen  follicles 
just  on  the  very  point  of  bursting,  over  which  the  infundibulum 
was  not  fixed.  In  such  a  case  the  ovum  must  fall  free  into  the 
peritoneal  cavity,  and  there  probably  dies  in  the  great  majority 
of  instances.  There  is  reason  to  suspect,  however,  that,  in  ex- 
ceptional instances,  it  there  undergoes  cystic  expansion. 


14  DISEASES   OF  THE   OVAEIES. 

The  iuf  undibulum  is  covered  by  transitional  columnar  epithe- 
lium, and  at  the  margin  of  the  fimbriae  it  meets  the  squamous 
epithelium  of  the  peritoneum,  forming  the  only  instance  of  the 
union  of  a  mucous  and  a  serous  surface — in  fact,  the  unique  in- 
stance of  an  opening  into  a  serous  cavity. 

Under  ordinary  circumstances,  when  the  tube  is  healthy,  its 
cavity  is  occupied  by  a  small  quantity  of  viscid  mucus,  and  dur- 
ing menstruation  this  is  replaced  by  blood  of  the  usual  dark, 
fluid  character.  Inflammation  may  occlude  both  ostia,  and  con- 
vert the  tube  into  a  cyst,  occupied  by  serum  (hydro-salpinx)  or 
by  blood  (hsemato-salpinx),  or  by  pus  (pyo-salpinx),  of  which 
conditions  I  have  seen  quite  a  number  of  cases. 

Normally  the  tube  lies  loose  in  front  of  the  ovary,  and  rather 
below  its  level,  coiling  around  it  till  the  infundibulum  turns 
toward  the  middle  line  and  backward  toward  the  posterior  sur- 
face of  the  gland.  This  bend  of  the  tube  may  be  actually  below 
the  ovary,  but,  as  far  as  the  structures  of  the  broad  ligament 
are  concerned,  it  is.  of  course,  above  it.  From  the  lower  margin 
of  the  mouth  of  the  tube  extends  the  tubo-ovarian  ligament, 
formed  by  one  of  the  major  fimbriae  {d,  Fig.  1),  and  which  seems 
to  serve  as  a  guide  for  the  tube  in  its  movement  toward  the 
ovary.  From  the  posterior  lip  of  the  funnel  depends  the  ter- 
minal bulb  of  Miiller's  duct,  though  it  is  by  no  means  always 
present. 

The  parovarium  is  the  remains  of  the  tubular  structure  of 
the  primordial  kidney,  or  the  Wolffian  body.  It  lies  between 
the  two  layers  of  the  broad  ligament,  between  the  upper  and 
outer  margin  of  the  ovary  and  the  Fallopian  tube.*  It  has  the 
shape  of  an  inverted  pyramid  (Fig.  4),  the  apex  being  applied  to, 
but  not  attached  to,  the  ovary.  The  tubules  vary  much  in  num- 
ber— from  three  or  four  to  thirty.  They  have  always  csecal  ex- 
tremities, and  those  on  the  outer  side  are  always  best  marked, 
the  outermost  one  forming  the  terminal  bulb  or  organ  of  Rosen- 
miiller.  If  a  good  example  of  the  structure  be  carefully  dis- 
sected, it  will  easily  be  determined  that  the  tubes  are  lying  loose 
in  the  cellular  tissue  of  the  broad  ligament,  and  are  not  attached 
to  either  of  its  layers  or  to  the  ovary.  This  explains  a  char- 
acteristic feature  of  those  Wolffian  cysts  which  require  opera- 
tion. From  the  inner  and  upper  angle  of  the  parovarium  runs 
the  atrophied  Wolffian  duct — that  is,  when  it  is  visible,  which  is 
not  often  the  case.  This  duct  is  so  thoroughly  atrophied  that  I 
do  not  think  any  of  the  tubules  have  intercommunication,  as 
they  would  have  if  it  were  not. 

Of  the  three  layers  of  the  blastoderm  which  form,  by  various 


ANATOMY    AND    PHYSIOLOGY    OF   THE    OVAllY. 


15 


and  most  curious  plications  and  developmental  changes,  the 
many  organs  of  the  body,  only  two — the  mesoblast  and  hypo- 
blast— take  part  in  the  formation  of  the  organs  we  are  consid- 
ering. 

The  first  change  consists  in  an  arrangement  of  cells  which, 
radiating  from  a  centre  which  forms  a  lumen,  is  found  to  travel 
down  through  the  mesoblast  from  its  dorsal  surface,  immedi- 
ately under  the  epiblast,  just  outside  the  protovertebrse,  between 
them  and  the  pleuro-peritoneal  cavity.  This  cavity  is  then  lined 
by  the  epithelium,  which  ever  afterward  is  its  marked  charac- 
teristic, and  which  then  is 
known  as  the  germinal 
epithelium.  In  the  chick, 
as  early  as  the  second  day, 
this  cellular  track  can  be 
traced  downward  as  a 
distinct  ridge  (Balfour), 
and  it  forms  the  primitive 
Wolffian  duct.  In  other 
animals  the  changes  are 
probably  much  the  same, 
but  for  obvious  reasons 
they  have  not  been  traced 
in  sequence,  and  their 
dates  are  unknown.  The 
next  change  is  the  appear- 
ance of  a  cell-mass  out- 
ward into  the  pleuro-peri-  ^ 
toneal  cavity,  in  which  the 
"Wolffian  body  is  formed, 
consisting,  like  the  per- 
manent kidneys,  of  con- 
voluted tubules,  commen- 
cing in  Malpighian  bodies 
with  vascular  glomeruli,  and  opening  into  the  duct.  Upon  this 
cellular  mass  lies  the  germinal  epithelium  of  the  pleuro-perito- 
neal cavity,  from  which  the  ovary  is  formed  on  the  inner  side  of 
the  Wolffian  body — that  is,  the  side  looking  toward  the  splanchno- 
pleure.  The  germinative  epithelium  retains  its  columnar  charac- 
ter, and  becomes  thickened  to  several  cells  deep,  the  mesoblast 
below  it  becoming  also  thickened,  so  that  a  distinct  eminence 
is  formed  as  a  fusiform  white  patch  or  streak,  extending, 
in  its  early  stages,  along  the  whole  length  of  the  Wolffian 
body,  but  subsequently  becoming  restricted  to  its  superior  por- 
tion.    In  the  cells  of  the  germinal  layer  are  found  the  primitive 


Fig.  6  (after  Balfour). — W),  mesentery  ;  X.  somaiopleure  ;  a', 
portion  of  the  genniiial  epithelium  from  which  the  involution 
to  form  the  duct  of  Miiller  {z)  takes  place  ;  a,  thickened  portion 
of  the  germinal  epithelium  in  which  the  primitive  ova  (C)  and 
(o)  are  lying ;  E^  modified  mesoblast,  which  will  form  the 
stroma  of  the  ovary  ;   ^\'K,  Wolffian  body ;  y.  Wolffian  duct. 


16 


DISEASES   OF   THE   OVARIES. 


ova,  developed  by  differentiation  from  the  epithelial  cells. 
This  change  is  effected  in  the  chick  about  the  ninetieth  hour  of 
incubation,  at  which  time  it  is  quite  possible  to  determine  the 
difference  of  sex.  In  the  human  embryo  the  difference  is  not 
discernible  till  between  the  fifth  and  seventh  weeks,  authorities 
differing  materially  as  to  the  exact  date. 

The  structure  of  the  early  ovary  consists  of  a  superficial  layer 
of  the  germinal  epithelium  {g,  e.  Fig.  7),  and  of  a  tissue  internal 
to  this  which  forms  the  great  mass  of  the  gland. 

The  germinal  epithelium  is  a  layer  about  0.03  to  0.04  mm. 
in  thickness,  having  two  or  three  layers  of  cells  with  granular 
nuclei.  The  outermost  layer  is  more  columnar  than  the  others, 
and  its  cells  have  nuclei  rather  elongated  than  round.  The  cells 
of  this  layer,  though  varying  in  size,  have  a  larger  provision  of 
protoplasm. 

The  tissue  of  the  body  of  the  gland  consists  mainly  of  col- 
umns of  epithelial-like  cells,  which  stain  more  deeply  with  osmic 
acid  than  those  of  the  germinal  layer,  having  round  nuclei  and 
a  more  limited  amount  of  protoplasm.     Between  its  columns 

runs  up  vascular  stroma, 
formed  of  spindle-shaped 
and  nucleated  cells  {t,  Fig. 
?).  This  tissue  continues 
visible  through  the  whole 
course  of  the  development 
of  the  ovary,  till  compara- 
tively late  in  life,  and  dur- 
ing all  the  earlier  stages  it 
might  be  easily  supposed 
to  be  playing  some  impor- 
tant part  in  the  develop- 
ment of  the  ova,  or  to  be  a 
part  of  the  germinal  epithe- 
lium, from  which  it  has 
only  occasionally  any  well- 
marked  line  of  demarca- 
tion. In  this  tissue  and  at 
the  base  of  the  ovary  are 
seen  a  number  of  canals 
wliich  have  given  rise  to 
the  view  advanced  by 
Pfliiger,  that  the  ovary  was  developed  as  a  tubular  gland.  This 
view  has,  however,  been  almost  universally  abandoned,  and.  in 
my  own  researches,  I  have  seen  no  evidence  which  entitles  it  to 
serious  consideration.     These  tubules  are  clearly  derived  from 


Fig.  7  (after  Balfour). — o,  e,  frerminal  epithelium ;  t, 
trabecwloB  ;  A,  hilum,  with  canal. 


ANATOMY   AND   PHYSIOLOGY   OP   THE   OVAKY. 


17 


Pig.  8  (after  Balfour). — p,  o,  primi- 
tive ova  ;  t  a,  tunica  albuginea  ;  c,  e, 
central  epithelium. 


the  Malpighian  bodies  of  the  Wolffian  structures,  and  are  mere 
survivals. 

The  germinal  epithelium  grows  rapidly  in  thickness  by  the 
division  of  its  cells,  and  the  vascular 
stroma  greatly  increases  in  quantity,  so 
that  the  epithelial  tissue  is  honeycombed 
by  the  vascular  trabeculse,  which  are  so 
arranged  as  to  divide  imperfectly  the 
epithelium  into  two  layers,  separated  by 
a  space  occupied  by  connective  tissue 
and  blood-vessels.  The  outer  part  is 
relatively  thin,  and  is  formed  of  a  super- 
ficial row  of  columnar  cells,  and  one 
or  two  rows  of  more  rounded  cells, 
among  which  can  be  recognized  the  primitive  ova  {p,  o,  Fig.  8) 
by  their  size,  their  granular  nucleus,  with  the  characteristic 
reticulation,  and  their  abundant  pro- 
toplasm. The  inner  layer  is  much 
thicker,  and  formed  of  large  masses 
of  rounded  cells,  and  the  two  layers 
are  connected  by  numerous  trabe- 
culse, the  stroma  between  which 
eventually  gives  rise  to  the  connec- 
tive-tissue capsule,  or  tunica  albugi- 
nea of  the  adult  ovary. 

Subsequently  in  the  course  of  de- 
velopment the  germinal  epithelium 
becomes  still  more  thickened  to  .38 
mm. ,  and  becomes  marked  into  three 


distinct  layers  (Fig.  9,  g,  e).  These 
consist  of  an  outer  epithelial  layer, 
having  an  average  thickness  of  .03 
mm. ;  a  middle  layer  of  small  nests, 
about  .1  mm.  in  thickness;  and  an 
inner  layer  of  larger  nests,  which 
has  an  average  thickness  of  .23  mm. 
In  these  three  layers  the  epithelium 
has  undergone  important  modifica- 
tions. The  greater  part  of  the  gran- 
ular contents  of  the  nuclei  of  the 
cells  has  become  clear,  the  other 
part  remaining  as  a  mass  taking  the 
color  of  staining  materials  very 
darkly,  and  somewhat  later  taking 
a  stellate  figure,  these  two  forms  being  spoken  of  as  the  granular 


Fio.  9  (after  Balfour). — g,  e,  germina! 
epithelium  in  three  layers ;  /;,  hilum,  with, 
canals,  c  c. 


18 


DISEASES   OF   THE   OVAKIES. 


and  stellate  stages  of  the  nucleus.  Still  later  the  nuclear  mass 
forms  a  beautiful  reticulation,  as  seen  in  the  spores  of  the  algae. 

As  already  said,  some  of  the  cells  enlarge,  and  are  recognized 
as  the  primitive  ova,  and  these  are  now  increased  in  number. 
Others  of  the  cells  again  diminish  in  size,  becoming  of  an  oval 
form,  the  nucleus  retaining  its  primitive  character,  and  not 
going  through  the  changes  above  described.  The  cells  subse- 
quently form  the  epithelium  of  the  Graafian  follicle.  They  may 
be  seen  arranging  themselves  around  the  primitive  ova  just 
formed.  At  the  hilum  of  the  ovary  the  tubules  {c,  c,  Fig.  9) 
have  by  this  time  almost  disappeared. 

As  the  ovary  grows,  the  outermost  layer  of  the  epithelial 
elements  becomes  more  and  more  separated  by  the  fusiform-cell 
stroma,  and  the  nests  of  the  middle  layer  become  smaller,  and 
finally  the  arrangement  and  formation  of  the  Graafian  follicles 
become  completed,  and  in  the  typical  epithelial  nest  are  to  be 
seen  fully-formed  follicles  with  the  permanent  ova,  completely 


Fig.  10  (artcT  Balfour).— Kest  from 
mifldle  layer,  showing;  formation  of 
follicular  ei)itht'liiim :  o.  primitive 
ovum ;  /e,  cells  forming  follicular 
epithelium;  do,  cells  which  disap- 
pear. 


Fig.  11  (after   Balfour), 
epithelial  nest. 


•  Typical 


enclosed  in  a  cavity  occui)ie(I  by  fluid  and  lined  by  epithelium  ; 
smaller  ova  {d,  o,  Fig.  10)  not  so  enclosed  ;  smaller  cells  (6,  c), 
with  modified  nuclei  of  doubtful  destination  ;  and  small  cells 
(/,  e)  obviously  about  to  form  follicular  epithelium.  The  inspec- 
tion of  a  single  such  nest,  says  Mr.  Balfour — and  in  this  I  fully 
concur — is  sufficient  to  show  that  the  follicular  epithelium  takes 
its  origin  from  the  germinal  epithelium,  and  not  from  the  stroma 
or  tubuliferous  tissue. 

Concerning  the  small  cells  with  modified  nuclei,  Mr.  Balfour 
suggests  three  possibilities,  and  thinks  they  may  have  all  three 
destinations  :  that  they  become  cells  of  the  follicular  epithelium, 
are  developed  into  ova,  or  are  absorbed  as  a  kind  of  food  by  the 
developing  ova. 


ANATOMY   AND   PHYSIOLOGY    OF   THE   OVAKY, 


19 


The  isolated  follicles  are  now  formed  by  ingrowths  of  the 
■connective-tissue  stroma  cutting  off  fully-formed  follicles  from  a 
nest.  They  occur  only  at  the  very  innermost  border  of  the  ger- 
minal epithelium.  This  is  in  accordance  with  what  has  so  often 
been  noticed  about  the  mammalian  ovary,  viz.,  that  the  more  ad- 
vanced ova  are  to  be  met  with  in  passing  from  without  inward. 
In  the  further  growth  of  the  ovary  the  pseudo-exjithelium  is 
formed  of  a  single  layer  of  columnar 
cells  with  comparatively  scanty  proto- 
plasm. In  it  there  are  present  a  con- 
siderable number  of  developing  ova.  A 
layer  of  connective  tissue,  the  albuginea, 
exists  below  the  pseudo  -  epithelium, 
which  contains  a  few  small  nests  with 
very  young  permanent  ova.  In  the  layer 
of  medium-sized  nests  internal  to  the 
albuginea  the  ova  have  all  assumed  the 
permanent  form,  and  are  provided  with 
beautiful  reticulate  nuclei  with  a  nucle- 
olus and  smaller  granular  bodies.  The 
majority  are  not  provided  with  follicular 
investment,  but  among  them  are  numerous  small  cells,  clearly 
defined  from  the  germinal  epithelium,  which  are  destined  to 
form  the  follicle  (Fig.  12). 
In  the  innermost  layer  of 
the  germinal  epithelium 
the  outlines  of  the  origi- 
nal large  nests  are  still 
visible,  but  many  of  the 
follicles  have  been  cut  off 
by  ingrowths  of  stroma. 


Fig.  12. — Further  development  of 
processes  seen  in  Fig,  10. 


The  general  conclu- 
sions from  Mr.  Balfour's 
researches  are  that  the 
whole  egg  -  containing 
part  of  the  ovary  is  really 
the  thickened  germinal 
epithelium,  and  it  differs 
from  the  original  thick-  ^jiii^ 

ened     patch     or     layer     of  ^i^.  1.3.— section  of  ovary  of  human  embryo  at  third  month 

I  .,,      ,.  (after  Kolliker),  slightly   magnified:  a,  mesovarium"    a',  vas- 

germmal         epitnellUm       cular  stroma  of  hilus  ;  6,  gland-substance.    X  50. 

mainly  in  the  fact  that 

it  is  broken  up  into  a  kind  of  meshwork  by  growths  of  vascular 

stroma. 


20 


DISEASES    OF   THE    OVARIES. 


It  will  be  seen,  therefore,  that  the  formation  of  true  Graafian 
follicles  goes  on  very  early  in  the  life-history  of  the  ovary,  long- 
before  the  birth  of  the  child,  a  fact  which  was  pointed  out  by 
Valisneri  in  1733,  but  which  received  but  little  attention  until 
the  writings  of  Carus  (1837)  and  Ritchie  (1842)  attracted  atten- 
tion to  this  most  interesting  subject.  Since  then  it  has  been  most 
exhaustively  discussed  by  many  observers,  and  finally,  and,  as 
I  think,  conclusively  unravelled  by  F,  M.  Balfour.  The  great 
practical  interest  which  it  has  for  surgeons  is  that  the  dropsical 
distentions  of  these  follicles  produce  ovarian  tumors  occasionally 
in  very  young  children  ;  and  Mr.  Cullingworth,  of  Manchester, 
has  placed  on  record  a  most  interesting  observation  where  an 
undoubted  ovarian  tumor  existed  in  a  newly  born  child,  and 
Virchow  alludes  to  similar  instances.  By  Mr.  Cullingworth's 
courtesy  I  have  been  able  to  examine  his  specimen,  and  I  have 
satisfied  myself  of  the  perfect  accuracy  of  his  description. 

A  most  interesting  observation  is  made  by  Dr.  De  Sinety,  who 
has  been  struck  with  the  frequency  of  apparently  cystic  ovaries 
in  children  at  the  time  of  birth,  and  especially  a  few  days  after, 
and  who  has  found,  in  the  great  majority  of  the  ovaries  of  chil- 
dren near  the  full  term,  or  who  die  a  few  days  after  mature  birth, 
that  Graafian  follicles  are  visible  to  the  naked  eye,  if  sections  of 
the  ovaries  are  made.  He  also  says  that  these  large  follicles, 
having  arrived  at  a  certain  stage  of  development,  begin  to  dis- 
appear, and  that  the  pro- 
cesses of  their  retrogres- 
sion and  the  different 
phases  of  the  cicatrices 
which  they  leave  behind 
them  can  be  followed. 
He  draws  attention  to 
the  fact,  familiar  to  every 
one,  that  it  is  no  unusual 
thing  to  see  slight  swell- 
ing of  the  breasts  of  new- 
ly born  children,  not  only 
female,  but  male,  and  the 
secretion  of  a  milky  fluid. 
This  generally  ceases  in 
a  few  days,  and  the  gland 
remains  quiescent  till  the 
puberty  of  girls,  and 
throughout  life  in  boys.  He  thinks  the  ovarian  activity  is  asso- 
ciated with  the  premature  mammary  effort,  and  he  quotes  Mer- 
kel  ("Ueberdie  Entwickelung  im  inneren  der  Samenkanalchen," 


Fig.  14.  — Spction  of  ovary  of  human  embryo  at  sixth  month  : 
fl,  external  epithrlial  layer  :  ft,  internal  e|)ithelial  layer ;  c,  vas- 
cular stroma  of  hilns ;  rf,  mesovarinm.     X  50. 


ANATOMY   AND   PHYSIOLOGY    OF   THE   OVAKY.  21 

Archiv  filr  Anatomie  und  Phys.,  1872),  to  the  effect  that  in  the 
new-born  male  a  considerable  proliferation  of  the  epithelium  of 
the  testicle  is  to  be  observed,  together  with  the  appearance  in 
that  organ  of  round  cellules  similar  to  those  from  which  sperma- 
tozoa are  derived  in  later  life,  and  that  these  cellules  disappear 
shortly  after  birth,  and  are  not  found  again  till  after  puberty. 
Similarly,  De  Sinety  has  not  found  developed  ovarian  follicles  in 
the  years  of  childhood. 

Haussman's  observations,  made  upon  eighty-four  examina- 
tions, completely  substantiate  De  Sinety's  conclusions.  He  found 
premature  development  of  the  Graafian  follicles  in  ten  per  cent, 
of  the  ovaries  examined,  and  he  puts  forward  the  important  sug- 
gestion that  such  a  condition,  by  exhausting  the  stock  of  the 
ova,  or  by  prematurely  discharging  the  activity  of  the  ovaries, 
may  be  a  possible  and  hitherto  unsuspected  cause  of  amenor- 
rhoea  and  sterility. 

These  observations  cast  a  most  interesting  light  upon  the 
parthenogenetic  theory  of  the  development  of  dermoid  cysts 
which  originated  with  Ritchie,  and  which  I  have  more  com- 
pletely elaborated  in  its  appropriate  chapter. 

This  ovarian  activity  seems  to  cease  about  the  third  month, 
for  after  that  time,  though  mature  Graafian  follicles  can  be 
discovered  by  microscopic  examination,  they  rarely  are  large 
enough  to  be  visible  to  the  naked  eye  ;  the  bands  of  connective 
tissue,  with  the  fusiform  cells  or  nuclei,  increase  in  size,  and  the 
tunica  albuginea  becomes  more  marked,  so  that  by  the  seventh 
month  the  ovary  presents  all  the  appearances  which  it  has  just 
before  puberty,  and  up  to  that  time  little  else  can  be  said  of  the 
history  of  the  gland.  The  only  point  which  yet  remains  to  be 
settled,  and  for  the  settlement  of  which  I  have  not  come  across 
any  evidence,  is  whether  or  not  the  premature  Graafian  folli- 
cles ever  rupture  and  discharge  their  nucleus  into  the  peritoneal 
cavity.  There  is  some  probability  that  they  do,  for  reasons  that 
I  shall  give  when  speaking  of  wandering  ova. 

That  most  of  the  Graafian  follicles  thus  produced — tliat,  in 
fact,  a  very  large  number  of  those  produced  in  adult  life,  includ- 
ing many  which  reach  almost  to  maturity — die  without  rupturing 
and  discharging  their  egg-nucleus,  is  rendered  certain  by  the 
observations  of  every  writer  on  the  ovary,  and  I  have  already 
indicated,  from  Balfour's  writings,  the  possibilities  of  their  ulti- 
mate fate. 

In  a  very  remarkable  paper  by  Dr.  Creighton,  of  Cambridge, 
published  in  the  thirteenth  volume  of  the  Journal  of  Anatomy 
and  Physiology,  that  author  sets  himself  to  answer  the  question. 
What  becomes  of  Graafian  follicles  within  which  the  ovum  has 


22 


DISEASES    OF   THE   OVARIES. 


decayed  ?  The  conclusions  he  comes  to  are  not  such  as  I  can  yet 
see  my  way  to  accept,  for  among  many  hundreds  of  sections  of 
the  ovaries  of  various  animals  in  my  possession  I  cannot  find  in 
one  indications  of  the  structures  which  he  describes,  and  the  ap- 
pearances he  figures  seem  to  me  to  be  such  as  may  arise  from 


a 


■<>0°%''o°S°O 


Fio.  15  ('after  Creif,'ht,(>n). — OIjsoI.-'scoiipo  ni  FollicU-s,  vsirions  stages. 

peculiarities  in  the  preparation  of  the  sections,  and  in  their  di- 
rection. I  can,  for  instance,  easily  accept  the  appearances  at 
A,  B,  C.  and  D,  Fig.  15,  as  being  sections,  or  slices  off  the  top  of  a 
Graafian  follicle,  and  the  drawing  at  G  may  similarly  be  a  slice 
out  of  a  corpus  luteum,  as  may  also  be  the  figure  at  F ;  but  I 


ANATOMY   AXD   PHYSIOLOGY   OF  THE   OVAKY.  2S 

must  say  that  I  completely  fail  to  follow  the  reasoning  which 
would  bring  us  to  regard  these  forms  as  being  homologous  in 
any  way  with  the  cortical  substance  of  the  supra-renal  body  fig- 
ured at  H.  The  paper  itself  is  well  worthy  of  perusal,  as  being 
full  of  information  of  undoubted  value,  and  it  may  be  that  some 
of  Dr.  Creighton's  conclusions  may  receive  a  fuller  acceptance 
than  I  can  give  them;  wherefore,  in  order  to  draw  attention  to 
them,  I  give  the  following  summary  of  them,  so  far  as  they 
deal  with  the  fate  of  the  decaying  Graafian  follicles  : 

"The  substance  of  the  ovum,  including  vitellus,  germinal 
vesicle,  and  spot,  disappears,  and  the  zona  or  vitelline  membrane 
is  found  more  or  less  empty  and  collapsed,  as  a  strong,  thick- 
walled  vesicle,  of  homogeneous  structure,  yellowish  color,  and 
either  ovoid  in  shape  or  somewhat  folded.  This  tough  mem- 
brane evidently  resists  the  influences  that  cause  the  vitellus  and 
germinal  vesicle  to  disappear,  and  it  is  difficult  to  discover  what 
eventually  becomes  of  it.  At  all  events,  in  later  stages  of  obso- 
lescence of  the  Graafian  follicle,  it  is  no  longer  to  be  seen,  and 
the  place  of  the  follicle  is  marked  only  by  the  persisting  belt  of 
follicular  epithelium.  The  fate  of  the  enclosing  zone  of  epithe- 
lium is  in  marked  contrast  to  that  of  the  ovum  within  it ;  in  pro- 
portion as  the  latter  shrivels  and  collapses,  the  former  assumes 
certain  determinate  and  fixed  characters,  by  which  it  may  be 
always  easily  recognized  in  the  midst  of  the  ovarian  stroma. 
The  follicles  drawn  in  Fig.  15  illustrate  various  stages  in  the  pro- 
cess of  obsolescence.  The  follicle  A  exemplifies  one  of  the  most 
fundamental  changes.  The  ovum  is  wanting  in  the  centre,  and 
the  zone  of  follicular  epithelium  persists  on  one  side ;  the  point 
that  it  is  of  importance  to  observe  is  the  form  of  the  epithelial 
cells. 

"  The  follicular  epithelium  does  not,  in  the  earlier  periods  of 
life,  present  the  usual  characters  of  an  epithelium  ;  the  cells  are 
round  and  almost  nuclear,  or  without  cell-substance.  Under  or- 
dinary methods  of  preparation,  and  under  a  moderate  magnify- 
ing power,  they  look  like  naked  nuclei,  just  as  the  lymphoid 
cells  of  a  lymphatic  gland  do  under  the  same  circumstances. 
As  the  follicle  becomes  riper  the  epithelium  becomes  more  cylin- 
drical ;  it  is  at  the  two  poles  of  the  nucleus,  and  not  uniformly 
all  round,  that  the  protoplasm  collects.  This  elongation  of  the 
epithelium,  which  is  never  very  pronounced  in  the  follicle  des- 
tined to  extrude  its  ovum  in  the  ordinary  course,  becomes  quite 
obvious  where  the  ovum  decays  within  the  cavity.  The  cells  are 
then  seen  (as  in  A.  Fig.  15)  to  be  greatly  elongated,  cylindrical 
cells.  In  B  and  C  the  elongation  of  the  epithelium,  and  the  cor- 
responding shrivelling  of  the  ovum,  are  seen  together ;  at  a,  in 


24  DISEASES   OF   THE   OVARIES. 

the  centre  of  each  follicle,  is  the  thick,  structureless  zona  of  the 
ovum,  which  appears  to  be  as  if  compressed  or  encroached  upon 
by  the  lengthening  radial  cells  of  the  follicular  epithelium.  At 
the  same  time  the  ends  of  the  cylindrical  cells  that  abut  upon 
the  zona  appear  to  have  acquired  a  common  bond  of  union,  like 
a  basement-membrane.  At  D  is  represented  a  belt  of  follicular 
epithelium,  broken  at  the  upper  side,  and  without  any  traces  of 
the  ovum  within  it.  The  follicle  E  exemplifies  perhaps  the  most 
common  appearance  of  the  belt  of  epithelium  surviving  after 
the  abortion  and  disappearance  of  the  ovum ;  the  originally 
circular  belt  (in  section)  has  become  almost  straight,  and  the 
shrivelled  zona  of  the  ovum  lies  toward  its  under  surface  and 
almost  clear  of  it.  The  different  forms  of  the  belt  of  follicular 
epithelium  depend  partly  on  the  plane  of  section  ;  but  there  is 
little  doubt  that  the  originally  circular  belt  (as  it  appears  in  sec- 
tion) unbends,  and  becomes  a  slightly  curved  cylinder,  the  shal- 
low concavity  of  which  corresponds  to  the  original  central  space 
where  the  ovum  lay.  At  F  is  shown  the  belt  of  epithelium 
doubled  up,  and  with  a  stalk  of  connective  tissue  issuing  from 
its  concavity.  These  various  surviving  conditions  of  the  follicu- 
lar epithelium  appear  to  belong  to  follicles  which  had  not  become 
greatly  expanded  ;  the  ovum  had  filled  the  central  space  exactly, 
and  there  had  been  no  development  of  liquor  folliculi.  There 
are,  however,  aborted  follicles  of  a  much  wider  circuit,  such  as 
that  represented  at  G  ;  in  this  case  the  extensive  belt  of  epithe- 
lium is  thrown  into  folds,  and  it  is  further  noticeable  that  the 
elongation  of  the  epithelial  cells  is  hardly  perceptible,  and  that 
there  is  no  uniform  basement  line  either  on  the  outer  or  inner 
surface  of  the  belt. 

"  The  peculiar  cortical  structures  of  the  supra-renal  bodies, 
and  their  position  relative  to  the  rest  of  the  organ,  may  be  read- 
ily made  out  in  any  good  section  of  a  well-prepared  supra-renal 
of  the  horse.  Fig.  15,  H,  is  a  low-power  view  of  such  a  section, 
made  perpendicular  to  the  surface.  The  outermost  stratum  is  a 
zone  of  connective  tissue  of  considerable  thickness.  Next  to 
that  comes  the  zone  of  peculiar  structures  above  referred  to." 

These  peculiar  cortical  bodies  of  the  supra-renals  Dr.  Creigh- 
ton  regards  as  homologous  to  the  remains  of  Graafian  follicles  in 
the  ovary,  from  which  the  ova  have  not  been  discharged,  but 
have  decayed.  His  conclusion  is  that  ''the  morphological  re- 
semblance between  the  ovarian  and  the  supra-renal  structures  is 
not  only  close,  but  it  is  complete."  I  must,  with  all  due  defer- 
ence to  the  work  of  an  observer  of  so  much  distinction,  say  that, 
so  far  as  I  can  see,  this  position  has  yet  to  be  proved. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  OVARY.        25 


The  Ovaries  at  Puberty. 

What  has  already  been  said  about  the  growth  and  ripening 
of  Graafian  follicles  before  puberty  constitutes  one  of  the  many 
arguments  in  favor  of  the  view  that  menstruation  and  ovulation 
are  wholly  distinct  processes,  and  abundant  examples  can  be 
given  of  them  being  carried  on  each  independently  of  the  other. 
The  statement  made  by  Dr.  Robert  Barnes,  that,  if  the  ovaries 
are  extirpated  or  become  atrophied,  menstruation  does  not  re- 
appear, is  not  accurate  ;  and  equally  incorrect  is  his  assertion 
that  the  first  ovular  dehiscence  corresponds  with  the  first  ap- 
pearance of  the  menses.  It  is  perfectly  certain  that  ovulation  is 
by  no  means  a  periodic  process,  in  the  sense  of  being  monthly, 
and  the  fact  that  a  periodic  flow  from  the  uterus  is  almost  con- 
fined to  the  human  race  is  sufficient  to  show  that  it  is  not  in  the 
ovaries  that  we  have  to  look  for  the  cause  of  this  curious  and 
objectionable  phenomenon,  for  which  no  one  has  ever  yet  sug- 
gested a  useful  object.  Where  this  cause  does  exist  we  do  not 
know,  but  it  is  quite  certain  that,  as  it  continues  for  months,  in 
some  cases,  after  the  removal  of  both  ovaries,  it  cannot  be  in 
those  glands.  ISTor  is  it  in  the  uterus,  for  in  most  cases  removal 
of  both  ovaries  arrests  the  function  immediately;  and  in  the 
somewhat  short  experience  I  have,  up  till  now,  had  of  the  re- 
moval of  small  ovaries,  this  has  been  always  immediately  ef- 
fected, and  completely,  when  I  have  been  obliged  to  remove  the 
tubes  as  well.  I  have,  therefore,  a  growing  suspicion  that  we 
shall  find  in  the  monthly  movement  of  the  tubes,  or  in  their 
structures,  at  any  rate,  the  real  source  of  the  monthly  discharge 
from  the  uterus. 

It  is  perfectly  certain  that  no  one  has  yet  recorded  one  in- 
stance in  which  the  tube  has  been  seen  fastened  on  to  the  ovary 
before  or  after  the  menstrual  period  of  life,  as  it  is  during  that 
period.  Yet  ovulation  goes  on  before  puberty  and  after  the  cli- 
macteric freely.  The  change  in  size  and  vascularity  of  the 
tubes  at  puberty,  and  their  diminution  at  the  climacteric,  and 
the  beginning  and  cessation  of  their  movements,  form  the  most 
curious  of  all  the  remarkable  features  of  those  functional 
changes,  and  are  quite  enough  to  show  either  that  the  tubes  are 
most  markedly  under  the  same  periodic  influence  as  that  which 
produces  the  menstrual  flow,  or  that  they  themselves  are  its 
cause.  Finally,  I  have,  during  the  last  few  years,  had  the  op- 
portunity of  seeing  the  ovaries  of  a  number  of  women,  whose 
abdominal  cavities  I  have  had  to  open  for  various  conditions  not 
connected  with  diseased  ovaries,  and  I  have  always  found  that 


26  DISEASES    OF   THE   OVARIES. 

during  menstruation  the  tube  is  fastened  on  the  ovary,  whether 
there  be  a  ripe  follicle  at  the  point  of  adhesion  or  not ;  that  both 
tubes  were  generally  fastened  to  their  respective  ovaries,  though 
in  one  ovary  there  may  have  been  no  appearance  of  a  ripe  ovi- 
sac ;  that  I  have  very  frequently  seen  an  ovisac  on  the  point  of 
bursting,  or  just  burst,  when  the  patient  was  midway  between 
two  menstrual  periods,  this  being  a  very  frequent  experience,  as 
I  always  selected,  when  I  could,  a  time  midway  between  the 
periods  for  my  operations,  and  in  these  cases  I  never  found  the 
tube  fastened  on  the  ovary.  Finally,  I  have  removed,  in  two 
cases,  ovaries  with  the  tubes  fastened  on  them,  during  menstru- 
ation, in  none  of  wliich  were  there  any  ovisacs  approaching 
ripeness. 

From  these  facts,  and  from  others  which  will  be  detailed  in 
another  chapter,  I  am  persuaded  that  ovulation  is  wholly  inde- 
pendent of  menstruation,  and  vice  versa;  that  the  most  impor- 
tant feature  of  the  menstrual  period  is  the  movement  toward 
the  ovary  of  the  trumpet-shaped  opening  of  the  tube,  and  the 
grasping  of  the  gland  by  it ;  that  this  grasping  continues  nearly 
throughout  the  period  of  menstruation,  and  that  it  is  only  a  mat- 
ter of  the  chance  of  there  being  a  ripe  ovisac  within  the  grasp  of 
one  or  other  of  the  tubes  that  true  ovulation — that  is,  the  pas- 
sage of  the  ovum  into  the  uterus — takes  place,  and  there  is  a 
possibility  of  conception.  If  this  be  not  so,  it  is  quite  impossible 
to  see  how  many  married  women  escape  having  progenies  im- 
mensely numerous,  seeing  the  numbers  of  ripe  ova  which  are 
produced,  and  the  regularity  of  menstruation.  If  ovulation  were 
coincident  with  menstruation,  the  probabilities  of  a  woman  with 
healthy  organs,  who  married  at  twenty,  and  ceased  to  menstruate 
at  forty-eight,  would  be  to  have  eighteen  children,  instead  of  six, 
which  is  her  average  as  at  present.  Besides  this,  the  number  of 
sterile  women  would  be  greatly  diminished,  and  the  increment  of 
the  human  population  would  exceed  all  management.  Diminish- 
ing our  death-rate,  or — to  speak  more  accurately,  as  we  should, 
for  we  all  must  die — increasing  the  average  death-age  as  we  do, 
by  the  abolition  of  wars  and  zymotic  diseases,  it  is  not  difficult 
to  sec  that  some  other  agency  must  step  in  to  aid  civilization. 
If  we  produced  as  many  young  as  do  the  lower  animals,  civili- 
zation would  be  an  impossibility  ;  the  life-struggle  would  be  so 
keen  that  barbarism  must  prevail.  The  inevitable  law  of  evolu- 
tion has,  therefore,  secured  some  process — we  do  not  yet  know 
what — by  which  the  proportion  of  reproduction  is  limited,  and 
we  are  Malthusians  despite  ourselves.  Look  at  the  myriads 
of  young  procreated  by  fish,  only  to  serve  for  food  to  tliemselves 
or  birds.     Between  them  and  ourselves  there  is  a  change  gradu- 


ANATOMY   AND   PHYSIOLOGY    OF   THE   OVAKY.  27 

ally  effected  through  the  whole  scheme,  till  we  produce,  as  a 
rule,  one  child  at  birth,  occasionally  two,  and  very  rarely  three 
or  four.  These  exceptions  are  clearly  atavic.  In  some  of  the 
higher  apes  there  are  signs  of  something  like  a  menstrual  pe- 
riod, but  as  all  such  features  in  animal  history  become  perverted 
in  confinement,  we  do  not  know  much  about  them.  But  in  the 
lowest  human  races  the  signs  of  menstruation  are  very  faint,, 
their  labors  are  very  easy,  and  their  whole  sexual  history  differ- 
ent from  that  of  the  highly  civilized  races.  It  is  abundantly 
proved  that,  just  as  civilization  (and  I  use  the  word  in  its  most 
literal  sense)  advances,  so  does  the  increment  of  sexual  trouble 
among  women.  The  flexions,  aiid  atrophies,  dysmenorrhoeas 
and  menorrhagias  which  affect  town-bred  women  are  compara- 
tively unknown  to  their  peasant  sisters,  and  the  healthily  abun- 
dant procreative  power  of  a  country  laborer's  wife  is  a  frequent 
source  of  envy  to  the  patrician  dame. 

In  all  this  menstruation  is  the  chief  factor,  and  I  suspect  the 
want  of  synchronism  between  the  embracement  of  the  ovary  by 
the  oviduct  and  the  discharge  of  the  ovum,  perhaps  also  the  in- 
complete maturation  of  the  ovum,  will  be  found  to  be  the  most 
important  features  of  the  change. 

That  menstruation  is  a  new  feature  in  sexual  life,  introduced 
high  up  in  the  scheme,  and  has  no  analogy  to  the  oestrus  or  rut 
among  the  lower  animals,  is  surely  proved  by  the  close  reason- 
ing of  Arthur  Farre  (article  Uterus :  Encyclopsedia  of  Anat.  and 
Phys.). 

The  changes  effected  upon  the  general  system  by  the  acces- 
sion of  puberty  do  not  concern  us  here,  and  therefore  I  shall 
limit  myself  to  those  concerning  the  ovary  and  oviduct,  and  for 
the  observations  on  which  my  conclusions  are  based  I  am  in- 
debted to  my  own  researches  entirely. 

The  structure  of  the  ovary  does  not  seem  to  be  changed  in 
the  least  by  the  accession  of  puberty,  save  in  its  vascular  ar- 
rangements. Before  puberty  the  mesovarium  is  thin  and  trans- 
parent, occupied  by  arteries  and  veins  probably  as  numerous  as 
they  are  afterward,  but  straighter  and  much  smaller,  the  veins 
especially  being  but  slightly  pronounced,  and  quite  different 
from  the  appearance  of  a  bag  of  purple  worms  which  they  often 
have  in  after-life.  After  puberty  these  vessels  become  convolu- 
ted and  distended.  The  ovary  itself  is  slightly  increased  in  size, 
but  no  very  marked  alteration  in  this  respect  is  to  be  made  out, 
a  matter  upon  which  Henning's  measurements  are  confirmatory. 
The  chief  alteration  consists  in  a  greater  size  of  the  arterioles,  a 
thickening  of  their  muscular  coat,  and  their  assumption  of  a  heli- 
coid  form,  which  I  have  been  wlioUv  unable  to  recognize  in  the 


28  DISEASES   OF   THE   OVAKIES. 

ovary  prior  to  puberty.  This,  however,  is  an  extremely  diflficult 
point  to  decide,  for  I  greatly  suspect  that  this  helicoid  arrange- 
ment of  the  arteries  in  the  ovary,  and  perhaps  in  other  glands, 
may  be  due  to  the  degree  of  tension  at  which  they  are  injected. 
It  is  at  best  difficult  to  make  out,  for  the  thickness  of  a  transpa- 
rent section  seems  but  rarely  to  contain  a  complete  coil,  and 
however  numerous  and  complete  the  coils  may  be,  it  is  not  diffi- 
cult to  see  that  the  method  of  examination  is  such  that  they  may 
be  missed.  I  have,  however,  so  often  seen  sections  of  such  heli- 
ces in  ovaries  after  puberty,  and  especially  in  the  glands  of  mul- 
tiparous  women — though  I  have  often  entirely  failed  to  find 
indications  of  them  in  similar  ovaries — that  I  cannot  help  think- 
ing that  there  is  some  reason  in  their  presence,  which  will  be 
found  to  affect  the  condition  resembling  the  engorgement  of 
erectile  tissue  which  the  ovary  assumes  during  menstruation, 
but  more  particularly  during  pregnancy  (v.  Homing).  In  nor- 
mally erectile  tissue  these  helices  have  been  regarded  as  the 
intrinsic  mechanism  of  the  engorgement — a  view  which  I  have 
never  been  able  to  accept,  for  I  have  never  realized  that  they 
can  be  more  than  a  means  of  permitting  the  elongation  of  the 
vessel  when  the  diameter  of  the  organ  is  increased.  When  it  is 
empty,  they  are  coiled  up  like  the  slack  of  a  rope,  and  therefore 
it  is  that  I  have  already  said  that  the  helices  present  in  a  mi- 
croscopical section  will  greatly  depend  on  the  tension  of  the  in- 
jection. If  the  organ  is  greatly  distended,  the  arteries  will  be 
straight.  If  slightly  distended,  they  will  or  may  be  coiled,  and 
I  think  it  quite  possible  that  my  not  having  found  them  in  ova- 
ries before  puberty  may  be  due  to  the  fact  that  the  tissue  of  the 
gland  is  then  more  easily  affected  by  distention,  and  that  their 
absence  may  be  from  faulty  preparation.  Still  it  is  likely  that 
the  altered  hsemic  condition  of  the  gland  after  puberty  may  pro- 
duce them. 

To  inject  an  ovary  before  puberty  is  not  an  easy  task,  and  to 
get  the  opportunity  of  examining  one  is  rare.  I  have  therefore 
not  been  able  to  get  perfectly  satisfactory  results  as  to  the  con- 
dition of  the  vascular  supply  of  the  ovisacs.  What  evidence  I 
have,  however,  shows  that  there  is  little  difference  in  it  from 
what  is  found  after  puberty  beyond  this,  that  it  is  possible  the 
vessels  are  all  larger,  though  upon  this  point  I  can  say  nothing 
positively.  But  of  this  I  am  certain,  that  all  the  phenomena 
which  occur  in  the  rupture  of  an  ovisac  and  the  closure  and  heal- 
ing of  the  cavity  are  in  common  occurrence  before  puberty, 
and  that  the  characteristic  arrangement  of  capillaries  in  what  is 
called  the  corpus  luteum  can  be  seen  long  before  the  occurrence 
of  menstruation. 


ANATOMY   AND   PHYSIOLOGY   OF   THE   OVARY.  29 

Spiegelberg  says  {Monatschrift  fiir  Geburtskunde,  18G7)  that 
he  has  seen  the  inner  layer  of  the  ovisac  distinctly  marked  off, 
and  possessed  of  a  yellow  color,  as  early  as  the  second  year  of 
life.  I  certainly  have  seen,  in  one  ovary  of  the  ninth  year,  an 
appearance  which  I  could  not  have  told  from  an  adult  corpus 
luteum  of  about  fifteen  days  after  the  rupture  of  the  ovisac. 

In  fact,  the  whole  process  of  ovulation  goes  on  before  puberty, 
and  the  only  difference  then  made  is  the  important  addition  of 
the  carrying  the  ovum  into  the  uterus,  and  the  possibility  of  its 
being  there  impregnated.  These  additions,  however,  do  not 
affect  the  function  of  the  ovary,  which  was  complete  before 
that,  as  is  proved  by  the  parthenogenetic  production  of  ovarian 
tumors,  and,  in  comparative  anatomy,  by  complete  partheno- 
genesis. 

It  will  serve  our  purpose,  then,  if  we  now  complete  the  de- 
scription of  the  normal  anatomy  of  the  ovary  by  detailing  the 
history  of  an  ovisac  after  its  formation. 

The  mature  human  ovum  measures  yio  of  a-n  inch  in  diam- 
eter, and  its  germinal  vesicle  probably  about  -^^  of  an  inch, 
though  its  exact  measurement,  free  from  yolk-substance,  has 
probably  not  yet  been  made.  The  nucleolus,  or  germinal  spot, 
is  about  yoVt  of  ^-n  inch  in  diameter.  The  ovum  lies  at  first 
centrally  in  the  ovisac,  or  Graafian  vesicle,  but  in  the  ripening 
of  the  latter  the  ovum  moves  toward  the  periphery  of  the  sac, 
and  is  always  to  be  found  close  to  the  surface  of  the  ovary  when 
the  sac  ultimately  bursts.  This  movement  is  variously  explained, 
but  the  more  certain  processes  are,  the  formation  of  a  liquor  fol- 
liculi  by  the  solution  of  the  epithelium,  especially  in  the  outer 
part  of  the  sac,  and  the  effusion  of  the  fluid  on  the  other  side  of 
the  ovum,  pushing  the  discus proUgerus  against  the  thinned  wall. 
This  wall  is  of  two  layers,  the  outer  being  formed  of  the  stroma 
of  the  ovary  and  the  peritoneum,  and  the  inner,  at  first  non- 
vascular, from  the  follicular  epithelium.  This  inner  layer  rapidly 
thickens,  becomes  vascular,  and  takes  on  a  distinct  yellow  color, 
long  before  the  follicle  is  ready  to  burst.  It  has  been  called  the 
memhrana  granulosa,  but  this  extra  name  does  no  more  than 
describe  one  of  its  characters,  and  leads  to  confusion.  It  is  the 
epithelial  layer,  and  it  thickens  everywhere  but  at  that  point 
where  the  ovum  lies  in  contact  with  it,  ready  to  issue  forth  at 
the  moment  of  rupture,  and  the  ovum  is  lightly  retained  in  its 
place  by  a  cellular  attachment  to  this  layer  at  the  indefinite 
margin  of  the  discus  proUgerus.  By  the  time  the  ovisac  is  ready 
for  rupture  this  layer  has  become  very  thick  and  vascular,  and 
is  composed  entirely  of  large,  round,  and  rapidly  growing  epi- 
thelial cells.     The  vascularity  of  the  walls  of  the  ovisac  is  most 


30  DISEASES   OF   THE   OVARIES. 

marked  at  the  point  of  impending  rupture,  and  its  vessels  are 
visible  to  the  naked  eye  on  the  surface  of  the  ovary.  The  rup- 
ture takes  place  at  last,  and  the  ovum  escapes  either  into  the 
peritoneal  cavity,  where  it  perishes,  save  in  exceptional  cases, 
or  into  the  pavilion  of  the  oviduct,  whence  it  is  conducted  to  the 
uterus.  1  believe  that  the  ovum  falls  into  and  perishes  in  the 
peritoneal  cavity  in  by  far  the  greater  number  of  cases,  and  that 
the  passage  of  it  into  the  uterus  occurs  only  in  a  small  minority 
of  the  ova  produced.  The  vessels  ruptured  in  the  act  of  the 
escape  of  the  ovum  bleed  slightly,  and  this  hemorrhage  occupies 
the  emptied  cavity,  and  must,  in  many  cases,  along  with  the 
liquor  folliculi,  also  pass  into  the  peritoneal  cavity.  I  have  re- 
peatedly seen  a  clot  hanging  from  a  ruptured  ovisac  into  the 
cavity  of  the  peritoneum,  and  on  one  occasion  I  saw  the  follicle 
rupture  before  I  had  touched  the  ovary,  which  lay  exposed  on  a 
uterine  tumor.  Si3iegelberg  (loc.  cit.)  tells  us  that  in  women  this 
hemorrhage  is  very  insignificant,  as  it  is  also  in  the  cow.  In 
the  mare  and  sheep  it  is  entirely  absent,  and  is  most  marked  in 
the  sow.  I  have  seen  nothing  to  make  me  believe  that  in  wo- 
men it  is  ever  so  severe  as  to  be  pathological,  but  I  can  easily 
imagine  that  sometimes  it  may  really  be  so,  and  may  explain 
those  rare  and  mysterious  cases  of  recurrent  pelvic  ha^matocele 
of  limited  extent,  of  which  I  have  lately  seen  a  most  curious  in- 
stance in  the  wife  of  one  of  my  professional  brethren. 

After  the  rupture  the  follicle  collapses,  and  the  thickened 
inner  coat  is  thrown  into  a  series  of  convolutions  strikingly  re- 
sembling those  of  the  brain,  though  I  am  by  no  means  sure 
that  these  convolutions  are  not  indicated  before  the  rupture 
occurs.  I  have  seen  them  in  an  unruptured  ovisac  before  pu- 
berty, but  as  the  ovary  had  been  pickled  in  chromic  acid  for 
section-cutting,  they  may  have  been  produced  by  preparation. 
I  have  also  seen  them  in  an  unripe  sac  opened  immediately  after 
removal  of  the  ovary.  Here  again  they  may  have  been  pro- 
duced instantaneously  by  the  relief  of  tension.  On  a  favorable 
opportunity  I  shall  freeze  a  fresh  ovary  before  cutting  it,  and 
settle  this  interesting  question. 

The  rent  in  the  ovisac  soon  heals,  and  the  cavity  is  again 
closed,  with  a  small  clot  in  its  centre,  and  this  clot  was  formerly 
accredited  as  the  source  of  all  the  phenomena  of  the  much-dis- 
cussed corpus  luteum.  It  deserves  no  such  distinction,  and  it 
soon  becomes  decolorized  and  is  absorbed,  so  that  the  points 
of  the  convolutions  come  into  contact,  ultimately  coalesce,  and 
finally  form  the  stellate  cicatrix  which  marks  for  a  long  time 
the  site  of  the  ovisac.  The  capillaries  of  the  inner  or  yellow 
<-,oat  are  very  regular,  and,  in  a  well-injected  section,  resemble 


ANATOMY    AND    PHYSIOLOGY    OF   THE    OVAKY.  1)1 

very  much  those  of  a  viUus  of  intestine.  They  sjjring  from  a 
small  helicoid  arteriole,  having  very  thick  muscular  walls  and 
two  layers  of  fibres  exactly  like  the  arterioles  of  the  kidney,  in 
the  outer  wall  of  the  ovisac.  This  arteriole  breaks  up  at  once 
into  a  ramifying  mesh  work,  which  seems  to  lie  between  the  two 
■coats  of  the  sac,  and  which  probably  provides  the  vessels  seen 
on  the  outer  surface  of  the  ovary  at  the  point  of  rupture.  From 
this  meshwork  straight  wide  capillaries  run  down  in  the  centre 
of  each  lobe  to  its  apex,  giving  off  small  branches  to  each  side. 
At  the  apex  of  each  villus  or  lobe  (from  a  section  it  is  quite  im- 
possible to  say  which  of  these  words  is  correct,  though  I  think 
lobe  would  be  the  proper  one)  comes  a  vein  which  runs  down  be- 
tween the  lobes  to  the  point  of  vascular  origin,  and  between 
these  interlobular  veins  and  the  intralobular  arteries  there  are 
universal  systems  of  capillary  communication.  Along  the  free 
margins  of  the  lobe  seems  to  run  a  system  of  communicating 
canals,  and  this  it  is  which  causes  me  to  regard  this  second 
system  of  vessels  as  the  veins,  together  with  the  fact  that  I  can- 
not make  out  that  they  have  thickened  muscular  walls.  In  the 
absence  of  a  successful  double  injection,  which  I  have  never 
accomplished,  this  interpretation  of  these  structures  may  be  in- 
accurate. Within  the  meshes  of  vessels  are  seen  the  regular 
round  epithelial  cells,  so  arranged  as  to  give  a  general  contour 
of  convolution,  and  in  the  cavity  are  the  altered  blood-corpuscles. 

The  lack  of  greater  precision  in  this  description  is  to  be  ex- 
plained by  the  fact  that  the  preparation  of  an  ovary  fortunate  in 
all  respects  is  very  difficult,  and  I  have  but  seldom  succeeded, 
and  that  for  some  years  now  I  have  been  too  much  engaged  with 
practice  to  follow  up  the  research,  which  requires  abundant  and 
uninterrupted  leisure. 

The  disappearance  of  the  red  color  of  the  central  clot  is  the 
first  change  observed  in  the  contracting  cavity,  and  with  this 
the  whole  forms  a  yellow  convoluted  patch.  As  it  contracts  the 
yellow  color  disappears,  this  change  being  effected  in  about  two 
months  in  the  non-pregnant  state.  The  microscopic  characters 
of  the  change  consist  in  the  disappearance  of  the  cells,  said  to 
be  brought  about  by  fatty  degeneration,  though  of  this  I  have 
seen  no  evidence.  This  absorption  is  accompanied  by  the  shriv- 
elling of  the  blood-vessels  and  their  final  disappearance,  so  that, 
in  eight  or  ten  months,  nothing  is  left  but  a  star-shaped  cicatrix 
extending  into  the  substance  of  the  ovary;  but  this  probably  in 
time  entirely  disappears  in  a  young  ovary.  After  impregnation 
these  changes  are  effected  much  more  slowly,  owing  to  the  al- 
tered nutrition  of  the  whole  organs,  so  that  the  yellow  color  may 
not  disappear  for  twelve  or  fourteen  months   (Farre),  and  the 


32  DISEASES    OF   THE    OVAKIES. 

shrinkage  of  the  cicatrix  may  take  two  years  to  be  effected.  It 
by  no  means  follows,  however,  that  an  ovisac  thus  delayed  in 
disappearance  has  been  the  seat  of  an  ovum  which  has  been 
fertilized,  for  I  have  seen  three  such  corpora  lutea  in  the  ovary 
of  a  woman  who  had  been  confined  only  seven  months  before 
my  operation,  of  one  child — her  only  one.  Farre  says  that  during- 
pregnancy  in  such  ruptured  ovisac  there  is  a  special  increase  in 
the  thickness  of  the  epithelial  lining,  and  a  larger  deposit  of  oil- 
granules,  but  I  have  failed  to  get  confirmation  of  his  statement. 
During  pregnancy,  and  for  some  time  after  it,  the  ovaries  are 
especially  increased  in  size  by  enlargement  of  their  vessels,  and 
so  are  the  contained  corpora  lutea.  The  distinguished  author 
just  quoted  says  :  "The  true  corpus  hitenm  is  the  follicle  in  its 
largest  condition  of  growth,  as  it  appears  after  impregnation ; 
Avhilst  in  all  other  conditions,  when  it  has  not  been  stimulated 
to  full  growth  by  imi^regnation,  and  whether  before  or  after  rup- 
ture, it  has  been  called  a  false  corpus  Juteum,  so  long  as  it  pos- 
sesses the  yellow  color.''  The  differences  are  therefore  only 
questions  of  degree,  and  cease  to  give  any  special  characters 
long  before  other  indications  of  pregnancy  have  passed  away. 
To  elevate  this  structure,  therefore,  into  a  medico-legal  impor- 
tance is  not  to  be  justified  ;  and  after  a  very  extensive  acquaint- 
ance with  ovaries  I  would  not  venture  to  give  an  opinion,  from 
any  number  of  corpora  lutea,  as  to  whether  they  indicated  past 
pregnancy  or  not.  The  great  battle  on  this  point  has  been  sin- 
gularly barren  of  results. 

At  puberty  a  very  marked  change  is  effected  in  the  appear- 
ance and  functions  of  the  Fallopian  tube  or  oviduct.  Before 
puberty  the  tube  is  small  and  straight,  and  the  size  of  the  fim- 
briae insignificant.  When  injected,  its  vascularity  is  not  a  very 
leading  feature,  and  certainly  presents  a  most  marked  difference 
to  the  peculiarly  abundant  blood-supply  visible  in  its  large- 
meshed  network  of  capillaries  in  adult  life.  The  muscular  fibres 
of  the  fimbriae  are  also  very  ill-defined  before  puberty,  and  no 
evidence  is  offered  by  any  one  that  it  ever  makes  any  kind  of 
functional  movement.  In  adult  life,  as  every  one  knows,  one  or 
both  tubes  seek  their  respective  ovaries,  and  become  attached 
to  them  for  a  time,  which  I  believe  to  be  concurrent  with  men- 
struation, by  cellular  adhesion.  Permanent  adhesion,  the  result 
of  peri-oophoritis,  is  often  met  with  in  women  who  have  led 
lives  of  prostitution,  and  in  them  a  sort  of  permanent  metrorrha- 
gia is  by  no  means  rare. 

In  the  tube  of  a  girl  under  the  age  of  puberty  I  have  been  un- 
able to  find  any  of  the  ciliated  epithelium  which  afterward  lines  it. 

My  conclusions  are,  therefore,  that  the  changes  in  the  ovary 


AXATOMY  AND  PHYSIOLOGY  OF  THE  OVAKY.        33 

at  puberty  are  entirely  vascular  ;  that  in  the  tube  they  are  vas- 
cular, muscular,  and  epithelial.  But  that  the  most  important 
change  of  all  is  the  functional  movement  of  the  tube,  the  ab- 
sence of  which  alone  makes  pregnancy  before  puberty  impossi- 
ble. Otherwise  h  do  not  believe  that  puberty  has  much  to  do 
with  procreative  power  in  women. 

During  the  climacteric  period  a  series  of  changes  are  effected 
in  the  sexual  apparatus  which  make  themselves  felt  throughout 
the  system,  but  the  results  of  which  are  not  apparent  in  the 
structures  themselves  for  some  considerable  time  after  the  meno- 
pause. Ritchie  and  others  have  shown  conclusively  that  the 
formation  of  true  ova  goes  on  long  after  this  event,  and  I  have 
seen  in  ovaries  of  very  old  women  structures  which  I  could  not 
have  decided  as  being  in  any  way  different  from  those  seen  in 
the  ovaries  of  women  at  the  prime  of  life.  It  is  quite  certain  that 
the  growth  of  ova  persists  till  the  end  of  life,  though  with  ad- 
vancing age  it  gets  feebler,  the  cells  become  less  numerous  and 
less  mature.  The  ovaries,  however,  continue  to  be  the  seat  of 
cell-growth,  and  pathological  cysts  are  formed  in  them  some- 
times even  at  the  very  extreme  of  old  age,  at  a  time  when  oper- 
ative interference  becomes  hopeless  on  account  of  the  age  of  the 
patient.    The  general  atrophy  which  accompanies  senility  affects. 


Fig.  16. — Ovary  at  menopause.     (Arthur  Farre.)  Fig.  It. — Senile  ovarj'.     (Arthur  Farre.) 

of  course,  the  ovaries,  and  late  in  life  they  are  usually  small  and 
shrivelled,  abundantly  marked  by  scars,  and  having  all  the  ap- 
pearances of  having  been  worked  out.  But  even  then  they  ex- 
hibit traces  of  all  their  old  products,  and  I  have  seen  an  ovary 
from  the  body  of  a  woman  nearly  seventy  years  of  age,  which 
it  would  have  been  impossible  to  say  might  not  have  been  re- 
moved from  the  body  of  a  woman  of  thirty. 

The  changes  which  are  most  apparent  are  those  effected  in 
the  uterus  and  tubes.  These  structures  rapidly  diminish  in  size, 
and  the  tubes  are  straightened  and  cease  their  movements. 
Here  we  have  further  proof  that  ovulation  and  menstruation  are 
wholly  independent,  that  menstruation  is  not  dependent  on  the 
ovaries  or  on  ovulation.  I  think  also  that  there  is  additional 
evidence  in  favor  of  the  view  to  which  I  am  inclined — that  men- 
struation is  wholly  a  function  of  the  Fallopian  tubes. 
3 


34  DISEASES   OF   THE   OVARIES. 

The  ovary,  then,  is  simply  a  gland,  developed  as  other  glands, 
and  formed  of  similar  elements  ;  its  peculiarity  is,  that  its  cell- 
nuclei  have  special  powers  during  a  certain  time  of  life  ;  and 
this  simplification  of  its  physiology  does  much  to  simplify  its 
pathology.  ^ 

A  few  sentences  from  Balfour,  concerning  the  phenomena 
observed  in  the  maturation  and  impregnation  of  the  ovum,  may 
here  be  fittingly  introduced.  I  take  them  verbatim,  as  it  is  a 
point  upon  which  I  have  made  no  research. 

*'  Every  ovum,  as  it  approaches  maturity,  is  found  to  be  com- 
posed of  (1)  a  protoplasmic  body  or  vitellus,  usually  containing 
yolk-spherules  in  suspension  ;  (2)  of  a  germinal  vesicle  or  nu- 
cleus, containing  (3)  one  or  more  germinal  spots  or  nucleoli. 
The  germinal  vesicle,  at  its  full  development,  has  a  more  or  less 
spherical  shape,  and  is  enveloped  by  a  distinct  membrane.  Its 
contents  are  for  the  most  part  fluid,  but  may  be  more  or  less 
granular.  Their  most  characteristic  component  is,  however,  a 
protoplasmic  network,  which  stretches  from  the  germinal  spot 
to  the  investing  membrane  ;  but  especially  concentrated  around 
the  former  germinal  spot  is  a  nearly  homogeneous  body,  with 
frequently  one  or  more  vacuoles,  occupying  one  of  the  eccentric 
positions  within  the  germinal  vesicle,  and  it  is  usually  rendered 
very  conspicuous  by  its  high  refrangibility,  is  sometimes  capable 
of  amoeboid  movements  (Auerbach  and  Hertwig),  and  is  more 
solid  and  more  strongly  tinged  by  coloring  agents  than  the  re- 
maining constituents  of  the  germinal  vesicle. 

"During  the  further  maturation  of  the  ovum  the  germinal 
vesicle  moves  toward  the  surface  of  the  egg,  its  membrane  be- 
comes absorbed,  and  it  is  metamorphosed  into  a  spindle-shaped 
body,  this  being  done  at  the  expense  of  the  germinal  spot.  One 
end  of  this  spindle  enters  a  protoplasmic  prominence  at  the  sur- 
face of  the  egg,  the  spindle  itself  dividing  then  into  two,  one 
half  remaining  in  the  egg,  the  other  in  the  prominence.  This 
prominence,  at  the  same  time,  becomes  nearly  constricted  off 
from  the  egg  as  a  polar  cell,  and  a  second  polar  cell  is  similarly 
formed.  That  part  of  the  spindle  remaining  in  the  egg  is  con- 
verted into  a  nucleus — the  female  pronucleus — and  this  is  moved 
toward  the  centre  of  the  egg.  On  the  entrance  of  one  sperma- 
tozoon into  the  egg  the  head  of  the  sperm  is  converted  into  an- 
other nucleus — the  male  pronucleus.  Around  this  latter  radial 
striae  immediately  appear,  and  these  travel  toward  the  female 
pronucleus.  The  fusion  of  the  two  pronuclei,  through  the  con- 
necting striae,  form  the  first  segmentation  nucleus." 


CHAPTER  II. 

ERRORS  OF  DEVELOPIVIENT  AND  DISPLACEMENTS  OF  THE  OVA- 
RIES AND  OVIDUCTS:  SALPINGITIS,  HYDROSALPINX,  PYO- 
SALPINX,  HEMATOSALPINX,  AND  FALLOPIAN  PREGNANCY. 

Uterus  unicornis  mit  Verlaufendes  Ovariumslinks.  Beigel.  Archiv  f iir  Gynaekolo- 
gie.     V.  XI. 

Doppelseitige  Hernii  ovarialis  inguin.  Werth.  Archiv  f  iir  Gynaekologie.  V.  XII. 
1877. 

Inguinal  Hernie  des  linken  Uteruskorpers.  Extirpation  desselben  und  des  linken  Ova- 
rium.    Leopold.     Archiv  fiir  Gynaekologie.     V.  XIV. 

Hyperaesthesie  des  Ovarium.     Geissler.     Schmidt's  Jahrbuch.     V.  172. 

Adnasion  und  Prolapsus  des  Ovarium.     Cleveland.     Schmidt's  Jahrbuch.     V.  176. 

Graviditas  ovarialis  und  tubo-ovarica.     Spiegelberg.      Schmidt's  Jahrbuch.    V.  182. 

Bin  Fall  von  Androgynie  des  richter  Eierstocks.  LlTTEN  and  Virchow.  Virchow's 
Archives.     V.  70. 

Ovarien  Prolaps.      Stocks.     Centralblatt  f.  Chir.     V.  I. 

Ovarialhernie.  AVeinlechner  and  Balleray.  Cent.  f.  Chir.,  V.  5,  and  Wiener 
med.  Wochenschrift.     1877. 

Prolapsus  of  the  Ovaries.     Munde.     Med.  Times  and  Gazette,  January,  1880. 

Absence  Probables  des  Ovaires.     Rheinstadler.     Ann.  de  Gyn.     V.  12. 

Prolapsus  of  the  Left  Ovary  in  a  Case  of  Retroversion.  American  Journal  of  Obstet- 
rics.    Vol.  X. 

Atrophy  of  the  Ovaries  in  Insanity.     DoRAN.     Obstet.  Journal,  December,  1S79. 

CoQgenitxl  Double  Inguino- Ovarian  Hernia.  Chambers.  Obstet.  Journal,  Decembei", 
1879. 

Hernia  of  Ovaries  Successfully  Operated  upon.  Works  of  Percival  Pott,  by  Earl.  Vol. 
II.,  p.  210. 

Recherches  sur  la  hernie  de  Tovaire      L.  C.  Deneux.     Paris,  1813. 

Des  hernies  de  I'ovaire.     PuECii.     Gazette  obstetricale  de  Paris.     1875. 

Hernia  Ovarialis.     Englisch.     Wiener  med.  Wochens.  Jahrbuch.     1871. 

Parthenogenecic  Development  of  Cysts  of  Ovary.  Tait.  Brit.  Med.  Journal,  Janu- 
ary 3,  1880. 

Prolapse  of  Ovaries.     Atthill.     Med.  Press,  December  10,  1880. 

Infantile  Uterus  and  Minute  Ovarian  Cysts.  Marey.  Amsrican  Journal  of  Obstet- 
rics, April,  1880. 

Rudimentary  Fallopian  Tubes  and  Ovaries.  Bowen^.  Med.  Record,  New  York,  June 
5,  1880. 

Prolapsus  of  Ovary  Relieved  by  Pessary.  Lyman.  Boston  Med.  and  Surgical  Jour- 
nal, April  1,  188  ). 

Hyperaesthesia  of  Orary.     Barlow.     Medical  Times  and  Gazette.     1877. 

Prolapse  of  Ovaries.     Skene.     American  Journal  of  Obstetrics,  April,  1879. 


36  DISEASES   OF   THE   OVARIES. 

Hernia  of  Ovary.     Bird.     Guy's  Hospital  Reports,  1878. 

Congenital  Hernia  ot  Both  Ovaries.  W.  Makeig  Jones.  Brit.  Med.  Journal,  Sep- 
tember, 1877. 

Prolapse  of  the  Ovaries.  PnoP.  Goodell.  Lessons  in  Gynecology.  Philadelphia, 
1880. 

Open  Fallopian  Tube.    D.  Mathews  Duncan.    British  Medical  Journal,  March,  1881. 

Note  on  the  Diagnosis  of  Extra-Uterine  Pregnancy.  Lawson  Tait.  Trans.  Obstet. 
Soc. ,  London,  1873. 

Des  grossesses  extra-ut^rines.     Tii.  Keller.     Paris,  1872. 

Extra-Uterine  Pregnancy.     Lloyd  Roberts.     London,  1878. 

Grossesses  extra-uterines.     Ditguet.     Annalea  de  Gynecologic.     1874. 

Memoir  on  Extra-Uterine  Gestation.     Wm.  Campbell.     Edinburgh,  1843. 

Extra-Uterine  Pregnancy.     John  S.  Parry.     London,  1876. 

Though  congenital  defects  of  the  ovaries  and  oviducts  are 
of  comparatively  rare  occurrence,  yet,  as  might  be  expected,  in 
the  case  of  a  gland  which  performs  functions  so  important  as 
those  of  the  ovary,  and  whose  functions  are  of  universal  exist- 
ence, complete  absence  of  the  gland  is  extremely  rare.  So  far 
as  I  have  been  able  to  find,  there  are  only  three  preparations  in 
this  country  indicating  complete  congenital  absence  of  the  ova- 
ries. Of  these,  two  exist  in  the  cases  of  malformed  foetuses,  in 
which  there  may  be  said  to  be  an  almost  complete  absence  of  the 
wliole  genital  apparatus.  The  third  occurred  in  the  case  of  a 
girl  who  died  at  twenty,  without  ever  having  menstruated ;  and 
in  that  case  also  the  whole  genital  apparatus  was  extremely 
defective. 

Like  every  other  organ  in  the  body,  the  ovary  is  liable  to 
arrests  of  development,  but  from  what  cause  or  causes  these 
arrests  arise,  it  is  not  very  easy  to  say.  This  is  a  question  which 
has  not  yet  received  sufficiently  careful  attention  ;  but  be  the 
cause  what  it  may,  it  is  quite  certain  that  whatever  arrests  the 
development  of  the  ovaries  equally  affects  the  development  of 
the  whole  of  the  genital  organs.  In  the  case  of  the  aves,  both 
ovaries  and  oviducts  are  equally  developed  in  the  embryo,  but 
on  one  side  an  atrophy  occurs  early  in  life  which  leads  to  a  total 
suppression  of  the  organs  on  that  side,  and  the  sexual  functions 
are  carried  on  by  the  left  side  only.  What  the  explanation  of 
this,  and  what  its  cause,  is  wholly  unknown.  I  am  not  aware 
that  any  similar  condition  is  known  to  be  of  even  occasional  oc- 
currence in  woman.  I  have  found  only  one  reference  to  the  ex- 
istence of  a  unilateral  arrangement  of  mature  organs,  quoted 
by  Busch  from  Chaussier,  in  the  case  of  a  woman  who  had  borne 
ten  children,  and  who,  on  post-mortem  examination,  was  found 
to  have  an  entire  absence  of  the  tube  and  ovary  of  the  left  side, 
and  apparently  an  absence  of  the  corresponding  side  of  the 
uterus.     When  the  ovaries  are  defective  it  is  almost  invariably 


ERKORS    OF   DEVELOPMENT   OF   OVARIES   AND    OVIDUCTS.       37 

the  case  that  the  other  organs  are  equally  ill-developed ;  but 
what  is  the  order  of  the  occurrence  is  not  in  any  way  clear. 

I  have  already  pointed  out  at  some  length,  and  I  shall  dis- 
cuss in  detail  in  a  subsequent  chapter,  the  effects  which  certain 
diseases  of  the  zymotic  type  have  upon  the  sexual  organs— more 
particularly  scarlet  fever.  As  this  disease  is  pecuHarly  incident 
to  childhood,  I  have  a  very  strong  impression  that  a  large  num- 
ber of  the  cases  of  incompletely  developed  sexual  organs  in  wo- 
men arise  from  the  effects  of  this  disease  in  childhood.  In  such 
cases  we  find  that  the  occurrence  of  menstruation  is  unduly 
protracted,  or  it  may  not  be  apparent  at  all ;  that,  at  the  time 
when  the  disturbance  should  occur,  a  number  of  vague  symp- 
toms make  their  appearance,  sometimes  trifling,  at  other  times 
extremely  serious.  If,  under  these  circumstances,  the  patient 
be  examined,  the  uteras  will  be  found  to  be  infantile  in  size,  an- 
teflected ;  and  if  a  post-mortem  examination  should  be  made, 
the  ovaries  will  be  found  small,  possibly  somewhat  puckered, 
the  mesovarium  but  slightly  indicated,  the  tubes  extremely 
small ;  and  should  the  patient  have  reached  mature  life  without 
the  occurrence  of  menstruation,  the  organs  will  be  found  to  pre- 
sent all  the  appearances  of  those  of  a  child  between  five  and  ten 
years  of  age. 

In  such  extreme  cases  the  development  of  the  whole  sexual 
apparatus  is  generally  imperfect,  the  sexual  appetite  is  in  abey- 
ance, and  there  may  be  comparatively  little  suffering  after  the 
first  few  months,  during  which  an  effort  seems  to  be  made  by  the 
system  to  establish  the  change.  This  is  provided  epilepsy  does  not 
supervene,  which  is,  however,  only  too  common  an  accompani- 
ment of  arrested  sexual  development  in  women.  Women  who 
are  thus  affected  have  frequently  an  absence  of  those  external 
peculiarities  of  their  sex  evident  in  roundness  of  form,  a  pi^o- 
nonce  bust,  smooth  and  hairless  skin,  and  highly  pitched  voice  ; 
and  they  often  partake,  in  some  slight  degree,  of  the  characters 
of  the  opposite  sex,  especially  in  the  growth  of  straggling  tufts 
of  hair  on  the  upper  lip  and  on  the  chin  in  a  line  with  the  canine 
and  premolar  teeth. 

A  greater  number  of  cases  have  the  arrest  at  a  later  stage, 
and  in  them  menstruation  is  established,  after  much  difficulty 
and  suffering,  between  sixteen  and  nineteen  years  of  age,  and, 
though  it  may  last  with  fair  regularity,  but  deficient  quantity, 
for  fpur  or  five  years,  it  then  ceases  completely.  In  many  of 
these  cases,  however,  if  marriage  should  occur  during  the  time 
that  menstruation  is  in  action,  and  if  the  patient  should  be  for- 
tunate enough  to  become  pregnant,  a  cure  may  result ;  that  is, 
her  periods  will  become  more  abundant,  and  her  suffering  less  ; 


38  DISEASES   OF   THE   OVARIES. 

her  health  will  be  improved,  and  she  may  go  on  menstruating 
for  many  years,  and  may  even  have  a  number  of  children.  Even 
without  the  occurrence  of  pregnancy,  marriage  often  establishes 
the  health  of  a  woman  afflicted  with  arrest  of  ovarian  develop- 
ment. 

The  great  bulk  of  cases  of  this  kind  are  those  which  are 
afflicted  to  a  less  degree,  but  whose  sufferings  are  nearly  always 
sufficient  to  require  medical  assistance  ;  and  it  is  a  singular  fact 
that  a  very  large  percentage  of  the  patients  are  found  to  be 
women  of  splendid  physical  development,  who,  to  any  but  one 
well  acquainted  witli  such  cases,  look  the  most  likely  to  possess 
capacity  for  procreation.  In  these  women  menstruation  is  estab- 
lished later  than  the  normal  time  by  a  few  months  or  a  year  or 
two.  They  have,  at  first,  irregular  times  and  much  pain,  but 
after  a  while  the  flow  is  established  with  normal  quantity  and 
regularity,  and  with  but  little  suffering.  In  this  way  they  go 
on  for  eight  or  ten  years,  and,  if  they  marry  in  the  interval,  their 
menstrual  career  may  run  an  ordinary  course.  If  they  remain 
single,  however,  they  begin  to  suffer  from  ovarian  dysmenor- 
rhcea  between  twenty-five  and  thirty,  and,  after  about  ten  years' 
suffering,  they  undergo  a  premature  climacteric  change.  It  is 
also  noticeable  in  these  women  that  their  menstrual  function  is 
suspended  on  slight  provocation.  Any  chronic  disease — even  of 
an  unimportant  nature — any  occupation  which  necessitates  an 
overstrain  on  their  system,  mental  anxiety,  or  sudden  fright, 
will  check  their  menstruation  for  months  or  years,  or  perhaps 
forever.  In  fact,  this  slight  excess  of  functional  power  which 
the  ovary  became  possessed  of  at  their  puberty  is  readily  and 
soon  exhausted,  and  its  extruded  cells,  on  slight  provocation, 
assume  an  immature  form,  and  the  systemic  conditions  become 
correlated.  In  fact,  in  such  cases  of  amenorrhoea,  and  similarly 
to  a  less  extent  in  those  of  dysmenorrhoea,  there  is  a  temporary 
resumption  of  the  infantile  condition  of  the  ovarian  functions  ; 
or  it  may  be  a  complete  and  premature  assumption  of  their 
senility.  The  amenorrhoea  of  pregnancy  and  lactation  are  also 
partial  resumptions  of  the  infantile  condition.  This  view  has 
been  admirably  expressed  by  Dr.  Charles  Ritchie  :  '*  In  early 
infancy,  extreme  old  age,  and  long-continued  organic  disease, 
the  ova  are  minute,  transparent,  and  structureless  ;  and  in  ad- 
vanced childhood,  soon  after  the  critical  age,  and  during  preg- 
nancy and  lactation,  they  are  more  or  less  organized,  large^,  and 
in  the  latter  stage  are  often  so  well  matured  that  about  one-third 
of  the  renewed  pregnancies  of  married  women  take  place  while 
they  nurse." 

In  these  slighter  cases  of  this  kind  of  dysmenorrhoea  the  uterus 


EREORS   OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      39 

is  generally  normally  developed,  and  it  is  frequently  so  in  some 
of  the  most  severe  cases.  There  is  a  converse  condition  where 
the  uterus  is  infantile  and  the  ovaries  normal,  much  more  rare 
and  far  more  severe  in  its  symptoms. 

In  all  such  cases  the  general  symptoms  are  pretty  constant 
and  distinctive.  Besides  the  menstrual  irregularities  and  defi- 
ciency, there  is  almost  always  a  persistent,  sickening,  and  well- 
marked  pain,  occurring  in  the  less  severe  cases  only  at  the  men- 
strual periods,  but  in  others  being  seldom  absent,  and  always 
greatly  increased  at  the  periods.  It  originates  in  the  ovarian 
region,  and  shoots  down  the  thigh,  often  also  down  the  leg  and 
around  to  the  back.  There  is  also  often  present,  especially  on 
the  accession  of  atrophy,  the  peculiar  submammary  pain  of 
ovarian  disease,  generall}''  felt  in  the  left  side  only.  Headache, 
nausea,  or  even  sickness  and  great  general  discomfort,  are  al- 
ways present  more  or  less. 

In  the  milder  cases  treatment  is  generally  successful  in  miti- 
gating the  sufferings,  and  often  the  ovary  may  be  made,  even 
in  some  very  well  marked  cases  of  arrested  development,  to  ful- 
fil its  functions  completely.  First  of  all  therapeutic  remedies 
there  stands  iron,  which  will  be  found  in  such  cases  to  be  of 
great  use,  even  though  there  should  be  no  general  indications 
for  its  employment.  There  can  be  no  doubt  that  many  forms  of 
this  remedy  have  a  specific  power  over  the  sexual  organs,  male 
and  female  ;  for,  in  a  case  of  chronic  metritis  or  subinvolution, 
smart  hemorrhage  may  be  induced  by  large  doses  of  iron.  In 
ovarian  and  tubal  dysmenorrhoea  it  is  best  given  during  the  inter- 
menstrual periods  in  small  doses,  one  to  five  drops  of  the  liquor 
ferri  perchloridi,  well  diluted,  and  increased  suddenly  to  fifteen 
or  twenty  for  a  day  or  two  previous  to  and  during  the  menstrual 
flow;  or,  quite  as  good,  is  the  substitution  of  an  iron  and  aloes  pill 
for  this  large  dose,  there  being  few  better  combinations  in  the 
pharmacopoeia  than  that  old-fashioned  remedy.  Hot  hip-baths 
and  leeches  to  the  perineum  at  the  period  are  often  useful  addi- 
tions, with  an  occasional  blister  on  the  sacrum.  To  such  as  this, 
the  treatment  of  delayed  or  difficult  menstruation  at  puberty, 
due  to  inefficient  ovarian  development,  must  be  confined ;  for 
the  other  means  are  only  allowable  in  ver}^  obstinate  cases,  after 
the  patient  has  been  married,  or  when  there  are  indications  of 
premature  ovarian  atrophy.  Marriage  is,  perhaps,  the  most 
efficient  remedy,  and  one  we  may,  under  certain  circumstances, 
recommend  ;  for,  even  if  the  patients  should  not  have  children, 
they  will  have  better  health,  and  they  may  even  become  preg- 
nant if  they  marry  early  enough  and  are  not  mismanaged. 

The  last  and  most  powerful  aid  is  mechanical  irritation  of  the 


40  DISEASES   OF   THE    OVARIES. 

uterus  ;  but,  as  it  is  not  free  from  risk,  and  therefore  requires 
careful  use,  it  is  not  always  to  be  recommended.  It  is,  besides, 
in  the  class  of  cases  where  the  uterus  is  most  at  fault  that  it  is 
least  risky  and  most  serviceable.  The  method  of  irritation  I 
generally  employ,  as  the  most  convenient  and  least  troublesome, 
is  the  insertion  of  Simpson's  galvanic  pessary.  This  instrument 
has  by  some  writers  been  very  much  decried,  but  I  think  by 
those  only  who  seem  to  have  used  it  indiscriminately,  and  with- 
out reference  to  a  proper  selection  of  cases. 

The  irritation  set  up  by  the  presence  of  a  galvanic  stem  in 
the  uterus  is  communicated  indirectly  to  the  ovaries  in  a  man- 
ner that  is  not  as  yet  explicable,  but  that  it  has  an  influence  is 
beyond  doubt,  and,  if  it  remain  within  bounds,  it  is  in  a  large 
number  of  cases  beneficial.  A  large  experience  has  shown  me 
that  it  is  only  in  occasional  instances  that  the  stem  cannot  be 
borne,  and  that,  if  carefully  watched  during  the  first  few  weeks 
of  its  use,  these  cases  are  easily  eliminated.  In  a  case  where  I 
have  been  led  to  regard  the  use  of  the  stem  as  advisable,  I 
always  begin  with  a  small  size,  and  after  this  has  been  Avorn  for 
two  or  three  months  I  change  it  for  a  larger  one.  For  the  first 
week  after  its  introduction  it  is  not  unusual  for  the  galvanic 
stem  to  give  rise  to  considerable  discomfort  and  even  positive 
pain ;  but  this  usually  passes  off  if  the  patient  keeps  her  bed  for 
a  few  days,  and  there  is  no  further  trouble  save  from  the  leu- 
corrhoeal  discharge,  which  is  a  part  of  the  process.  The  action 
of  the  stem  is  not  purely  mechanical,  as  has  been  stated  ;  for, 
very  soon  after  its  insertion,  the  zinc  becomes  coated  with  an 
albuminous  deposit,  from  which  the  copper  is  free,  and  the  zinc 
becomes  corroded.  It  is  certain,  therefore,  that  there  is  a  gal- 
vanic action  set  up,  and  the  stimulating  effects  are  due  partly 
to  this,  and  partly  to  the  interior  of  the  uterus  being  constantly 
bathed  in  a  weak  solution  of  chloride  of  zinc.  However  pro- 
duced, it  is  certain  that  the  uterus  rapidly  enlarges  under  the 
action,  and  there  is  every  reason  to  believe  that  the  ovaries  take 
part  in  the  increased  activity.  If  once  the  uterus  becomes  ac- 
customed to  the  presence  of  the  galvanic  stem,  it  may  be  worn 
for  many  months,  and  the  longer  it  is  retained  the  more  perma- 
nent will  be  the  benefit;  but  if,  after  a  trial  of  a  few  months — say 
four  or  five,  there  is  no  apparent  alteration  for  the  better,  the 
attempt  should  be  given  up,  and  the  case  considered  as  hopeless. 

In  a  very  large  number  of  cases  of  incompletely  developed 
ovaries  another  remnant  of  infantile  life  is  met  with  in  an  exag- 
geration of  the  normal  curve  of  the  uterus,  amounting  some- 
times to  complete  anteflexion,  and  in  this  class  of  cases  the  ge^' 
vanic  stem  is  especially  serviceable. 


ERKORS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      41 

The  results  of  my  attempts  to  arrest  premature  atrophy  of 
the  ovary  from  any  cause,  when  once  begun,  have  been  far  from 
satisfactory ;  and  this  has  been  more  especially  the  case  vs^hen 
that  atrophy  has  been  due  to  a  constitutional  disease,  such  as 
tubercle.  Sir  James  Simpson  had  a  belief  that  the  pretubercular 
amenorrhoea,  so  often  seen  in  young  women,  was  a  cause  of  the 
subsequent  disease  ;  and  he  therefore  directed  his  attention  to 
the  restoration  of  the  utero-ovarian  function  as  a  means  of 
treatment  or  prevention  of  the  consumption.  From  the  views 
previously  expressed,  it  will  easily  be  seen  that  I  consider  his 
theory  to  be  based  on  error,  though  in  some  cases  his  treatment 
would  seem  to  have  been  successful ;  but  how  much  of  his  suc- 
cess was  due  to  local  and  how  much  to  general  treatment  cannot 
now  be  determined.  It  is  not,  however,  a  practice  likely  to 
meet  with  many  followers. 

It  will  be  seen,  therefore,  that  not  only  is  the  ovary  extremely 
liable  to  be  arrested  in  its  growth  from  childhood  to  adolescence, 
but  it  is  also  liable  to  have  induced  upon  it  a  condition  of  prema- 
ture senility.  It  is  unlike  most  of  the  glands  of  the  body  in  that 
it  has  its  functions  limited  to  a  particular  period  of  life,  or  at 
least  the  period  during  which  these  functions  are  complete  is  so 
limited — and  therefore  it  seems  possible,  and  to  be  of  not  unfre- 
quent  occurrence,  that  the  period  of  complete  functional  ac- 
tivity is  very  materially  shortened.  This  I  think  we  shall  after- 
ward see  to  be  by  no  means  unusual  after  first  confinements, 
more  particularly  after  miscarriages  which  occur  early  in  sexual 
life  ;  for  the  number  of  women  who  come  under  my  care  is  large 
in  whom  the  history  is  uniformly  given  of  an  attack  of  pelvic 
inflammation  after  the  first  pregnancy,  and  who  have  suffered 
from  distress  from  that  date,  and  have  never  again  become 
pregnant.  The  explanation  of  this  will  be  found  in  the  adhe- 
sions formed  by  the  tubes,  to  be  afterward  described. 

The  most  common  displacement  of  the  ovary  is  dislocation 
downward  into  the  retro-uterine  pouch,  to  which  the  name  of 
prolapse  of  the  ovary  has  been  given,  as  I  think,  somewhat 
improperly.  I  have  very  little  doubt  that  a  large  number  of 
women  go  about  with  marked  dislocation  of  their  ovaries  down- 
ward, without  any  kind  of  suffering  ;  and  there  is  equally  no 
room  for  doubt  that  this  dislocation  is  in  many  cases  a  source 
of  suffering  so  great  as  absolutely  to  prevent  the  woman  from 
fulfilling  her  duties  in  life,  and  to  render  her  life  a  prolonged 
misery. 

The  origin  of  this  peculiar  dislocation  is  very  various.  I  have 
no  doubt  that,  in  some  of  the  cases  I  have  seen,  the  position  of 
the  ovaries  in  the  cul-de-sac  was  congenital ;  in  others  the  dislo- 


42  DISEASES    OF   THE   OVAllIES. 

cation  has  probably  arisen  from  some  accidental  strain  ;  but  in 
by  far  the  largest  number  of  cases  it  has  been  due  to  some  acci- 
dent during  the  process  of  involution  of  the  uterus  after  a  con- 
finement or  a  miscarriage.  In  a  large  number  of  cases  it  is 
associated  with  retroversion  or  retroflexion  of  the  uterus,  but  in 
others  the  uterus  is  nearly  normal  in  direction,  and  then  we  can 
only  assume  that  there  has  been  some  relaxation  of  the  perito- 
neal investments  of  the  ovaries,  by  which  they  have  been  allowed 
to  drop  downward  and  give  rise  to  the  trouble. 

There  can  be  no  doubt  that  by  far  the  larger  number  of  these 
cases  arise  in  a  condition  which  is  practically  that  of  subinvolu- 
tion, and  in  two  anatomical  facts  we  have  a  complete  explana- 
tion of  this  result.  Turning  to  Henning's  table  (p.  4),  it  will 
be  found  that  the  ovary  of  the  puerperal  woman  is  extremely 
large — indeed,  nearly  twice  as  large  as  it  is  at  any  other  time. 
It  is  also  extremely  remarkable  that  the  left  ovary  increases  in 
the  puerperal  woman  to  a  much  larger  extent  than  does  the 
right,  a  circumstance  which  I  have  no  doubt  is  fully  explained 
by  the  want  of  a  valve  in  the  left  spermatic  vein  (v.  p.  b).  As 
the  ovaries  rise  in  the  abdomen  with  the  pregnant  uterus,  their 
ligaments,  their  tubes,  and  everything  connected  with  them  rise 
in  proportional  degree.  It  is  not,  therefore,  to  be  wondered  at 
that  any  incident  which  interferes  with  the  subinvolution  of  the 
uterus  after  parturition  should  also  affect  the  ovary.  One  of 
the  most  common  results  of  subinvolution  of  the  uterus  is  retro- 
flexion, and  therefore  it  is  that  we  have  a  large  number  of  these 
cases  of  dislocation  of  the  ovaiy  downward  associated  with  this 
uterine  displacement ;  and  my  experience  is  entirely  in  accord 
with  that  of  Professor  Goodell,  when  he  says  that  if  we  find  a 
dislocated,  or,  as  he  calls  it,  a  "prolapsed"  ovary,  it  is  almost  sure 
to  be  the  left.  It  is  therefore  practically  a  subinvolution  of  the 
ovary  with  which  we  have  to  deal ;  and  as  in  the  uterus  we  have 
hyperaemia  of  the  organ  gradually  passing  into  chronic  metritis, 
so  we  have  a  similar  process  occurring  in  the  ovary,  and  in  sev- 
eral remarkable  cases,  in  which  I  have  been  obliged  to  remove 
the  ovaries  on  account  of  extreme  suffering,  I  have  found  the 
organs  in  a  condition  of  clironic  inflammation  and  greatly  en- 
larged, associated  with  chronic  fundal  metritis  and  enlargement 
of  the  whole  l)ody  of  the  uterus.  In  these  cases  intractable 
menorrhagia  has  been  a  leading  symptom,  and  the  monthly  en- 
gorgement involved  by  the  process  of  menstruation  leads,  of 
necessity,  to  an  increase  of  the  symptoms  and  an  exaggeration 
of  the  pathological  condition. 

The  history  of  such  a  case  as  this  Avill  generally  be  that  of 
some  disturbance  after  confinement,  followed  by  a  prolonged 


ERRORS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      43 

convalescence  from  childbed,  a  speedy  resumption  of  menstrua- 
tion, great  difficulty  and  pain  in  locomotion,  almost  always  pain 
on  defecation,  and  pain  during  sexual  intercourse.  Besides 
these  local  symptoms,  there  will  be  very  often  a  number  of  more 
or  less  distinct  reflex  symptoms,  such  as  headache,  pain  in  the 
breasts,  pain  in  the  back,  and  pains  travelling  down  the  thighs. 
The  loss  at  the  monthly  periods  will  increase  until  it  may  amount 
to  absolute  flooding.  The  patient  becomes  anaemic,  dyspeptic, 
and  suffers  from  symptoms  of  extreme  mental  depression,  and 
in  course  of  time  she  will  become  an  absolute  invalid. 

On  examination,  the  uterus  will  be  found  to  be  markedly  re- 
troverted  or  retroflected,  or  both,  the  fundus  usually  being  much 
enlarged.  It  may  happen,  however,  that  the  uterus  will  retain 
its  normal  direction,  though  it  will  be  rarely  found  that  it  is  of 
normal  size.  Great  care  must  be  taken  in  the  examination  to 
ascertain  the  position  of  the  fundus,  because  it  is  quite  possible 
to  mistake  an  enlarged  and  dislocated  ovary  for  a  retroflected 
fundus,  and  vice  versa.  But  the  fundus  may  easily  be  recog- 
nized with  a  little  care,  by  finding  that  the  tumor  felt  is  con- 
tinuous with  the  cervix.  The  temptation  may  be  great  to  replace 
this  by  means  of  the  sound,  but  I  would  strongly  urge,  especially 
on  the  beginner  in  gynecology,  not  to  yield  to  this  temptation. 
The  sound  is  a  most  dangerous  implement,  and  in  the  record  of 
more  than  one  of  my  cases  it  will  be  found  that  an  immense 
increase  of  suffering  has  resulted  from  this  practice.  The  expe- 
rienced gynecologist  should  generally  be  able  to  replace  the  de- 
pressed fundus  by  the  point  of  his  finger,  and  if  he  is  unable  to 
do  this  in  any  particular  instance,  he  may  suspect  that  there  is 
some  adhesion  which  will  make  it  much  safer  not  to  use  the 
sound.  The  leverage  of  the  sound  in  such  a  case  will  exercise 
an  amount  of  force  of  which  the  operator  may  have  no  exact 
knowledge,  and  which  is  likely  to  do  more  harm  than  good.  If 
I  may  here  venture  to  sum  up  my  experience  of  this  instrument, 
extending  over  more  than  twenty  years,  I  would  say  that  it  has 
done  an  infinite  amount  of  mischief,  and  that  probably  Ave  should 
have  lost  nothing  if  it  had  never  been  invented,  and  that  the 
more  experience  grows  in  practice  the  less  will  this  instrument 
be  used. 

If  the  tumor  in  the  cul-de-sac  be  found  not  to  be  the  fundus, 
then  the  probability  is  that  it  is  an  ovary;  and  if  it  be  an  ovary, 
and  not  adherent,  it  may  easily  be  pushed  upward  in  the  direction 
of  its  proper  place,  and  this  will  generally  be  found  to  be  toward 
the  left  side.  If  it  be  an  ovary,  the  peculiar,  dull,  sickening  pain 
evinced  by  pressure  will  at  once  declare  its  nature,  and  if  it  can- 
not be  easily  replaced  by  the  finger,  it  may  be  assumed  that  it  is 


44  DISEASES    OF   THE   OVARIES. 

adherent.  The  conditions  may  be  fully  established  by  the  bi- 
manual method  of  examination,  and  in  all  probability  this  will 
not  be  done  with  perfect  satisfaction  without  the  assistance  of 
an  anaesthetic,  and  ether  is  by  far  the  best  agent  to  use.  By 
this  method  of  examination  it  should,  first  of  all,  be  ascertained 
whether  or  not  the  ovaries  are  in  their  proper  place  on  each  side 
of  the  uterus.  If  they  cannot  be  found,  it  is  most  probable  that 
the  retro-uterine  tumor  is  an  ovary,  and  more  particularly  if  it 
be  adherent  I  would  recommend  the  greatest  caution  in  dealing 
with  it,  for  I  have  more  than  once  seen  a  smart  attack  of  pelvic 
peritonitis  set  up  by  too  rough  handling.  If  the  tumor  be  a 
fundus,  it  will  probably  easily  be  dealt  with  ;  but  if  it  be  an 
ovary,  very  great  difficulty  indeed  may  be  met  with  in  treating 
the  case  satisfactorily.  If  the  gland  is  not  adherent,  it  may  be 
replaced  by  a  pessary,  adapted  so  as  to  keep  it  in  place,  or  at 
least  far  enough  up  to  be  out  of  harm's  way;  but,  if  it  be  ad- 
herent, it  may  be  taken  as  certain  that  no  pessary  can  be  borne. 
The  best  pessary  for  this  purpose  is  one  which  I  introduced 
many  years  ago,  under  the  name  of  the  "wedge  pessary,"  and 
which  is  here  figured.     I  have  frequently  had  cases  brought  to 

me  in  which  the  sufferings  of 
the  patient  had  been  greatly  in- 
creased by  well-intended  efforts 
to  replace  by  pessary  an  adher- 
ent ovary. 

The  general  treatment  should 
consist  of  absolute  physiological 
rest ;  that  is  to  say,  that  during 
the  menstrual  period  the  patient 
should  be  confined  absolutely  to 
bed,  and  that  there  should  be  a 
Fig.  i8.-w«ige  Pessai-y.  ccssatiou  of  intercoursc.     Any 

kind  of  treatment  which  will 
tend  to  improve  the  patient's  general  health  should  be  em- 
ployed, and  by  far  the  most  effectual  remedy  will  be  a  judicious 
administration  of  ergot  and  the  salts  of  potash.  What  has 
proved  in  my  experience  to  be  the  best  method  of  giving  these 
drugs  is  to  put  the  patient  on  a  prolonged  course  of  the  bro- 
mide and  chlorate  for  alternate  months,  in  doses  of  from  five 
to  twenty  grains  twice  daily,  and  taken  continuously;  and  to  this 
is  to  be  added  a  pill  containing  from  half  a  grain  to  two  grains 
of  ergotin,  to  be  taken  for  a  few  days  before  the  appearance  of 
menstruation,  and  during  the  whole  of  the  period.  I  am  bound 
to  say  that  no  other  treatment  by  drugs  has  seemed  to  me  to  be 
of  the  slightest  use.     Professor  Goodell  speaks  in  high  praise  of 


ERKORS    OF   DEVELOPMENT   OF   OVARIES   AND    OVIDUCTS.      45 

a  combination  of  the  amnionic  and  mercuric  chlorides,  but  I 
have  not  found  them  of  much  use.  He  gives  them  in  the  fol- 
lowing formula  : 

]J .     Hydrargyri  chloridi  corrosivi gr.  j. 

Ammonii  chloridi 3  ij. 

Mist,  glycyrrhizse  co f.  Ix]. 

M. 

S. — One  dessertspoonful  after  each  meal,  in  a  wineglassful  of 
water. 

In  addition  to  this,  Professor  Goodell  recommends  treatment 
by  the  genu-pectoral  position,  as  introduced  by  Dr.  Campbell ; 
and  in  some  cases  of  dislocated  ovaries  which  were  not  adherent, 
accompanied  by  retroflexion  and  subinvolution  of  the  uterus,  I 
have  found  this  plan  to  be  distinctly  effectual.  It  is,  however, 
very  harassing  to  the  patient,  for  it  requires  prolonged  use,  and 
I  have  not  found  many  women  sufficiently  persevering  to  give 
it  an  extended  trial ;  the  misfortune  in  these  cases  being,  like 
very  many  others  in  this  line  of  practice,  that  almost  any  treat- 
ment requires  to  be  continued  for  so  long  a  time  that  most  suf- 
ferers are  apt  to  lose  patience,  and  seek  other  treatment  at  the 
hands  of  some  fresh  practitioner.  I  take  the  following  descrip- 
tion of  this  postural  treatment  from  Professor  Goodell's  writings : 

"  A  very  excellent  way  of  keeping  up  the  ovaries — one  which, 
in  every  case,  I  adopt,  and  one  which  I  shall  now  teach  this  pa- 
tient— is  the  knee-breast  posture,  devised  by  Dr.  C.  F.  Campbell, 
of  Georgia.  Two  or  three  times  a  day,  or  more  frequently  if 
needful,  this  woman  will  unhook  her  dress,  loosen  her  under- 
clothing, and  kneel  on  her  bed  as  she  now  kneels  on  this  table. 
Her  body  is  then  bent  forward  until  the  breast  is  brought  down 
to  the  surface  of  the  bed,  while  her  head  is  turned  to  one  side 
and  supported  in  the  palm  of  her  left  hand.  Her  knees  should 
be  about  ten  inches  apart,  and  the  thighs  perpendicular  to  the 
bed.  If  she  now  refrains  from  straining,  and  breathe  naturally, 
a  reversal  of  gravity  will  be  established.  With  the  fingers  of 
her  free  hand  she  will  next  open  her  vulva.  Air  will  rush  in, 
and  the  abdomen  and  its  contents  will  at  once  sag  down.  This 
will,  of  course,  draw  up  the  womb  and  the  displaced  ovaries  out 
of  the  pelvic  canal.  As  it  is  rather  awkward  for  a  woman,  while 
in  this  posture,  to  free  one  hand  and  reach  the  vulva.  Dr.  Camp- 
bell advises  that,  previously  to  taking  this  attitude,  she  should 
insert  into  the  vagina  a  small  glass  tube,  open  at  both  ends,  and 
long  enough  to  project  externally.  This  will  leave  an  air-way, 
and  dispense  with  the  use  of  the  fingers.     With  such  tubes  as  I 


46  DISEASES    OF   THE   OVAKIES. 

now  show  you  I  furnish  each  one  of  my  patients  ;  but  you  will 
find  a  good  substitute  in  the  empty  barrel  of  the  old-fashioned 
cylindrical  "female  syringe,"  as  it  is  called.  After  staying  in 
this  posture  for  a  few  minutes,  the  woman  will  remove  the  tube 
and  slowly  turn  over  on  her  side,  where  she  will  lie  as  long  as 
she  can.  Such  constant  replacements  are  of  great  service,  for 
they  lessen  the  throbbing,  they  give  the  limp  ligaments  a  chance 
of  shrinking,  and  they  teach  the  ovaries  good  habits  of  staying 
at  home.'' 

It  will,  however,  often  happen  that,  after  all  kinds  of  treat- 
ment have  been  employed,  and  many  practitioners  consulted 
without  the  slightest  improvement,  or  even,  it  may  be,  only  with 
the  result  of  increasing  the  patient's  sufferings,  that  she  settles 
down  as  a  permanent  invalid,  her  life  being  rendered  absolutely 
miserable,  and  she  being  hopelessly  invalided  by  her  dislocated 
ovary.  Then  there  remains  as  her  only  hope  the  operation  of 
ovariotomy.  The  discussion  of  this  important  subject  is  by  no 
means  yet  complete,  and  it  is  unfortunately  one  in  which  much 
unnecessary  and  most  unfair  criticism  has  been  introduced.  I 
shall  in  another  chapter  consider  more  fully  the  arguments  upon 
this  question,  but  here  it  will  probably  be  quite  enough  to  quote 
again  the  words  of  Professor  Goodell,  with  the  remark  that  I 
endorse  every  word  which  he  says  : 

"Once  in  a  while,  however,  such  lasting  tissue-changes  take 
place  in  the  ovaries  as  no  medication  can  reach.  The  hypertro- 
phied  glands  keep  heavy,  and  refuse  to  float  up.  Now,  must  the 
unfortunate  owner  of  these  organs  drag  out  the  rest  of  her  men- 
strual life  burdened  with  the  distressing  ovaralgia,  the  crippled 
locomotion,  and  with  all  those  aches,  and  pains,  and  throbs 
which  I  have  described  to  you  ?  No,  indeed  !  The  source  of  all 
this  mischief — the  ovaries  themselves — must  be  removed.  Nor 
need  you  fear  that  such  an  oj^eration  will  unsex  a  woman.  In 
the  cases  in  wliich  it  has  been  performed  by  myself  and  by 
others  it  in  nowise  changed  the  voice,  the  appearance,  or  the 
character  of  the  woman.  It  merely  brought  on,  more  abruptly 
than  nature  does,  that  change  of  life  which  every  w^oman  longs 
to  reach,  and  which,  Avhile  taking  away  all  hope  of  future  off- 
spring, makes  her  no  less  a  mother  or  a  wife." 

A  great  deal  of  discussion  has  taken  place  concerning  the 
merit  of  having  first  proposed  this  operation,  and  Dr.  Marion 
Sims  has  thrown  the  whole  weight  of  his  justly  great  authority 
in  claiming  for  it  an  American  origin  ;  and  for  Dr.  Battey  he 
asserts  the  credit  of  it,  having  named  it  "Battey's  operation."' 
I  must,  however,  in  justice  to  myself,  protest  against  this;  and 
I  have  to  point  out  that,  so  far  as  the  records  of  this  operation 


ERRORS    OF   DEVELOPMENT   OF   OVARIES   AND    OVIDUCTS.      47 

are  known,  Professor  Hegar,  of  Fribourg-im-Breisgau,  was  the 
first  to  perform  it,  and  that  my  first  case  preceded  that  of  Dr. 
Battey  by  several  days — all  three  operations  having  been  per- 
formed within  a  fortnight.  Further,  I  have  to  point  out  that  in 
the  first  edition  of  this  book,  written  in  1872  and  published  in 
1874,  the  essay  to  which  was  awarded  the  Hastings  gold  medal 
of  the  London  meeting  of  the  British  Medical  Association,  the 
following  passage  occurs  : 

"  The  ovaries  are  liable  to  certain  displacements,  which  may 
give  rise  to  many  disagreeable  symptoms  without  any  actual 
disease  of  the  gland.  Thus,  one  or  both  ovaries  may,  by  a  re- 
laxation of  their  peritoneal  investments,  drop  into  the  retro- 
uterine cul-de-sac,  and  there  be  a  source  of  great  trouble.  This 
will  be  especially  the  case  if  there  be  at  the  same  time  retro- 
flexion or  retroversion  of  the  uterus ;  for  I  have  known  such  a 
displacement  of  an  ovary  utterly  to  prevent  the  application  of 
any  apparatus  for  the  replacement  of  the  uterus,  and  cause  so 
much  suffering  as  almost  to  make  us  discuss  the  question  of 
ovariotomy." 

The  details  of  the  history  of  this  operation  will  be  fully  dis- 
cussed in  a  special  chapter. 

In  cases  where  the  pelvic  viscera  are  displaced  downward  so 
as  to  form  more  or  less  complete  protrusion,  the  ovaries  of  course 
share  in  the  dislocation,  and  they  may  incidentally  increase  the 
amount  of  distress  caused  by  such  a  condition  ;  but  as  this  be- 
longs more  to  diseases  of  the  uterus,  I  shall  not  dwell  further 
upon  it ;  and  similarly  may  dismiss  the  displacement  of  the 
ovaries  involved  in  the  inversion  of  the  uterus.  A  more  rare 
displacement  of  the  ovary  occurs  as  the  result  of  an  excess  of 
embryonic  transition,  the  gland  being  carried  downward  and 
forward  in  the  direction  taken  by  the  testicles  of  the  male  in  the 
course  of  descent.  I  have  not  been  fortunate  enough  to  have 
had  any  experience  of  this  peculiar  form  of  hernia,  and  what  in- 
formation I  can  give  upon  it  must  be  by  quotation.  It  is,  how- 
ever, a  matter  of  such  importance  that  I  feel  perfectly  justified 
in  quoting  at  length  some  of  the  more  notable  cases  which  have 
been  placed  on  record.  The  instance  which  has  attracted  most 
attention  is  that  narrated  by  Mr,  Percival  Pott,  of  a  patient, 
aged  twenty-three,  admitted  to  St.  Bartholomew's  Hospital,  who 
had  two  small  swellings,  one  in  each  groin,  which  had  been  for 
some  months  so  painful  as  to  entirely  prevent  her  following  her 
occupation  as  a  domestic  servant.  Her  menstruation  had  been 
perfectly  regular,  and  the  tumors  were  more  painful  at  that 
time.  Mr.  Pott  found  the  tumors  to  be  the  ovaries,  which  had 
come  down  through  the  inguinal  canal.     He  removed  them  sue- 


48  DISEASES   OF   THE   OVARIES. 

cessfully,  and  the  patient's  health  and  comfort  were  speedily 
and  completely  re-established ;  and  menstruation  never  reap- 
peared, the  last  observation  on  this  point  having  been  made 
several  years  after  the  operation.  In  the  record  of  the  case  no 
mention  is  made  as  to  whether  or  not  Mr.  Pott  removed  the 
tubes,  or  any  part  of  them.  In  the  work  of  L.  C.  Deneux  many 
very  remarkable  examples  of  displacement  of  the  ovary  are 
given,  such  as  its  appearance  under  the  crural  arch,  through 
the  ischiatic  notch,  as  part  of  the  contents  of  an  umbilical  her- 
nia, and  of  various  eccentric  ventral  and  vaginal  protrusions. 
Dr.  Busch  gives  seventy-eight  similar  observations  which  he  has 
collected,  including  fourteen  cases  in  which  there  was  more  or 
less  pronounced  absence  of  the  uterus,  thirteen  cases  of  various 
kinds  of  spurious  and  true  hermaphroditism,  and  four  of  uni- 
cornual  or  bicornual  uterus.  These  observations  go  to  show — 
and  I  think  all  the  facts  of  comparative  anatomy  indicate  it— 
that  the  male  organism  is  an  advance  upon  that  of  the  female, 
and  that  these  cases  would  have  to  be  regarded  more  as  arrests 
of  development  in  the  direction  of  the  male  organs  than  hyper- 
erchesis  of  the  female. 

Kiwisch  narrates  an  instance  of  an  ovary  forming  part  of  a 
hernia  through  the  foramen  ovale.  When  the  ovary  is  displaced 
in  this  way,  it  is,  of  course,  quite  as  apt  to  undergo  cystic  de- 
generation as  an  ovary  in  its  normal  position  ;  and  therefore  it 
is  not  surprising  to  find  that  there  is  at  least  one  case  on  record 
where  a  cystic  ovarian  tumor  has  been  removed  from  outside 
the  inguinal  ring.  One  of  the  most  remarkable  cases  on  record 
is  that  published  by  Mr.  W.  M.  Jones,  in  the  British  Medical 
Journal  for  1877,  in  which  the  patient  seems  to  have  had  double 
congenital  hernia  of  the  ovaries,  and  yet  became  pregnant. 

"A.  E.  C ,  aged  twenty-three,  came  to  the  out-patient  room 

on  August  1st,  complaining  of  dragging  pains  about  her  abdo- 
men and  a  swelling  in  both  labia.  She  was  married,  and  had 
one  child.  Ever  since  she  could  remember,  when  she  stood  up 
a  small  lump  descended  into  each  labium,  going  back  again  on 
lying  down.  She  had  always  suffered  from  pains  in  the  abdo- 
men, and  at  her  menstrual  periods  the  lumps  themselves  were 
painful.  On  examination,  a  small,  roundish  tumor  was  found 
in  each  labium,  feeling  like  a  testicle,  and  quite  easily  returnable 
into  the  abdomen  through  the  inguinal  canal.  It  was  perfectly 
dull  on  percussion,  and  there  was  no  impulse  on  coughing.  Dou- 
ble ovarian  hernia  was  at  once  diagnosed,  and  the  diagnosis  was 
confirmed  on  her  coming  the  following  week,  during  her  cata- 
menial  period,  with  both  tumors  swollen  and  tender.     An  ordi- 


ERRORS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      49 

nary  double  inguinal  truss  was  given  her,  which  effectually  pre- 
vented the  descent  of  the  tumors,  and  she  reported  herself  last 
week  as  being  quite  well,  and  entirely  free  from  her  abdominal 
pains.  The  great  interest  in  this  case  lies  in  its  analogy  to  the 
descent  of  the  testicle  in  the  male,  and  in  the  fact  that,  notwith- 
standing the  malposition  of  both  ovaries,  she  had  actually  been 
impregnated,  and  given  birth  to  a  living  child." 

Dr.  Werth,  of  Kiel,  narrates  an  instance  of  removal  of  both 
ovaries  on  account  of  double  ovarian  inguinal  hernia.  The  pa- 
tient was  twenty-three  years  of  age,  and  had  never  menstruated, 
but  at  each  monthly  period  there  was  severe  abdominal  pain. 
The  vagina  was  occluded,  the  clitoris  was  unusually  large,  and 
was  furnished  with  a  large  prepuce ;  and  under  the  skin,  over 
the  inguinal  canal  on  each  side,  was  a  body  about  the  size  of  a 
pigeon's  egg,  resembling  a  testicle  in  shape  and  consistence. 
These  bodies  lay  symmetrically  in  the  axis  of  the  inguinal  canal, 
the  upper  end  corresponding  to  the  inguinal  ring,  while  the 
lower  and  inner  end  corresponded  to  the  anterior  margin  of  the 
labium  majus.  At  the  upper  part  of  each  body  was  an  ill- 
defined  substance  of  the  size,  form,  and  consistence  of  an  epi- 
didymis. They  were  both  quite  irreducible,  and  looked  so  very 
like  testicles  that  the  sex  of  the  patient  was  extremely  doubtful. 
An  operation  was  undertaken  for  their  removal,  which  was 
completely  successful,  and  on  subsequent  examination  they 
proved  to  be  unquestionable  ovaries,  for  they  possessed  the  char- 
acteristic follicles  containing  ova. 

Weinlechner  {Wiener  med.  Wochenschrift,  1877)  relates  a 
case  of  inguinal  hernia  produced  by  a  stumble,  and  for  which  a 
truss  had  been  worn  for -eighteen  weeks,  when  it  came  down 
again  and  became  irreducible.  This  was  followed  by  vomiting 
and  acute  pain  ;  as  taxis  failed,  and  the  symptoms  of  incarcera- 
tion became  more  severe,  she  was  admitted  into  hospital.  In  the 
right  groin  was  a  tumor  the  size  of  a  goose-egg,  which  was 
marked  into  two  divisions  by  Poupart's  ligament.  The  symp- 
toms of  incarceration  were  not  quite  perfect,  and  the  patient  as- 
serted that  the  hernial  tumor  increased  at  the  menstrual  periods, 
that  the  probability  of  an  ovarian  hernia  was  recognized,  and  it 
was  confirmed  by  operation.  The  swollen  and  irreducible  ovary 
was  removed  after  ligation  of  its  pedicle,  and  the  patient  recov- 
ered well. 

Dr.  J.  H.  Balleray  has  written  an  extremely  interesting  paper 
upon  a  case  of  this  kind,  to  which  he  appends  some  valuable  ref- 
erences, and  I  therefore  here  insert  the  whole  of  his  observations. 

"  The  hernial  tumor  was  large,  and  seemed  to  be  divided  into 
4 


50  DISEASES   OF   THE   OVARIES. 

two  portions  by  a  sulcus ;  the  skin  covering  it  was  somewhat 
inflamed  and  tender  to  the  touch.  There  was  something  very 
pecuHar  about  the  feel  of  the  tumor,  especially  at  its  lower  por- 
tion. The  sensation  communicated  to  the  finger  was  such  as  to 
satisfy  me  at  once  that  I  had  to  deal  with  something  out  of  the 
usual  order  of  things,  but  as  to  what  the  real  character  of  the 
hernial  tumor  was  I  had  no  definite  idea.  I  therefore  requested 
my  friend,  Dr.  E.  J.  Marsh,  to  see  the  case  with  me.  He  did  so, 
and  seemed  to  be  as  much  puzzled  as  I  was.  He  suggested, 
however,  the  possibility  of  the  ovary  having  found  its  way  into 
the  hernial  sac.  Taxis  having  failed  to  effect  reduction  of  the 
hernia,  and  the  patient's  condition  being  critical,  both  Dr.  Marsh 
and  myself  were  convinced  that  an  operation  was  imperative, 
and  that  it  should  be  performed  without  delay. 

"  Having  informed  the  patient's  husband  of  the  result  of  our 
deliberations,  he  requested  that  we  should  proceed  with  the  opera- 
tion at  once,  if  in  our  judgment  it  was  necessary.  Accordingly, 
with  the  kind  assistance  of  Drs.  Marsh  and  Rogers,  I  proceeded 
to  operate.  Having  cut  down  to  the  sac,  this  was  cautiously 
opened,  and  about  four  ounces  of  brownish  yellow  fluid  escaped, 
when,  to  ray  surprise,  there  was  neither  intestine  nor  omentum 
to  be  seen,  but  the  left  ovary  w^as  found  lying  near  the  lower 
portion  of  the  sac,  and  tightly  strangulated  by  a  firm,  fibrous 
band,  which  extended  from  one  wall  of  the  sac  to  the  other,  and 
constricted  the  ovary  at  about  its  upper  third.  This  band  was 
divided,  and  the  ovary  liberated.  It  was  found  to  be  very  deeply 
congested,  but  as  its  vitality  did  not  seem  to  be  destroyed,  I  de- 
cided, after  consultation  with  my  confreres,  to  return  it  into  the 
abdominal  cavity.  The  wound  was  then  closed  in  the  usual 
way,  a  pad  and  bandage  applied,  and  the  patient  put  to  bed. 

"She  rallied  well  from  the  operation,  and  at  the  end  of  the 
third  week  she  was  convalescent.  The  enterocele  returned,  how- 
ever, after  she  began  to  walk  about,  and  she  has,  therefore, 
been  obliged  to  wear  a  well-adjusted  truss,  which  enables  her  to 
attend  to  her  household  duties  with  a  greater  degree  of  comfort 
than  she  had  enjoyed  for  years  before. 

"  In  January,  1864.  Mr.  Holmes  Coote  reported,  at  a  meeting 
of  the  Royal  Medical  and  Chirurgical  Society,  a  'case  in  which 
the  left  ovary  was  found  in  the  sac  of  an  oblique  inguinal  her- 
nia.' A  young  woman  was  brought  into  St.  Bartholomew's  Hos- 
pital with  a  swelling  in  the  left  groin,  and  suffering  from  the 
symptoms  of  strangulated  hernia.  In  the  course  of  a  few  hours 
the  usual  operation  was  performed,  when  the  ovary  and  Fallo- 
pian tube  were  found  in  the  sac.  The  left  ovary  was  removed, 
some  thickened  omentum  cut  away,  and  the  patient  was  put  to 


EUUORS   OF   DEVELOPMENT   OF   OVARIES   AND    OVIDUCTS.      51 

bed ;  but  the  sickness  and  constipation  continued,  and  she  died 
four  days  after  the  operation.  The  cause  of  the  sickness,  etc., 
was  displacement  of  the  stomach  and  transverse  arch  of  the 
colon.  In  the  discussion  which  followed  the  report  of  this  case, 
Mr.  Caesar  Hawkins  stated  that  he  had  met  with  two  cases  in 
which  the  ovary  was  found  in  the  hernial  sac.  In  one  of  these 
the  patient  was  an  elderly  woman,  and  died  of  peritonitis.  In 
these  cases  he  thought  the  better  practice  was  to  leave  the  ovary 
in  the  sac,  as  its  removal  was  attended  with  danger. 

"  Dr.  Frank  H.  Hamilton,  of  New  York,  assisted  by  Dr.  Terry, 
collected  reports  of  twelve  cases  of  ovarian  hernia  occurring  in 
the  inguinal  region,  inost  of  which  were  operated  upon  before  a 
diagnosis  was  made.  These  cases  were  published  in  the  '  Belle- 
vue  Hospital  Reports,'  1870,  p.  159.  Dr.  Hamilton  himself  has 
seen  one  example  of  congenital  ovarian  inguinal  hernia.  The 
late  Dr.  J.  C.  ISTott  met  with  a  case  of  ovarian  hernia  at  the  in- 
guinal ring,  in  a  lady  sixty  years  of  age,  which,  being  strangu- 
lated, he  was  able  to  reduce  by  taxis.  A  very  interesting  case 
is  also  reported  by  Dr.  Alfred  Meadows,  in  the  '  Transactions  of 
the  Obstetrical  Society  of  London,'  vol.  iii.,  p.  438. 

"  In  cases  of  strangulated  ovary,  the  question  as  to  whether  the 
ovary  should,  after  division  of  the  stricture,  be  returned  into  the  ab- 
dominal cavity  or  left  in  the  hernial  sac,  ought,  in  my  judgment, 
to  be  determined  by  the  condition  of  the  organ  itself.  The  rule 
by  which  the  surgeon  is  governed  in  the  management  of  strangu- 
lated intestine  or  omentum  is,  I  think,  applicable  to  these  cases. 

/'According  to  Hamilton  ('Principles  and  Practice  of  Sur- 
gery'), JSTeboux,  Mulert,  and  Krieger  returned  the  ovary  into  the 
abdomen,  and  their  patients  got  well.  Deneux,  on  the  other 
hand,  cut  away  the  ovary,  and  the  patient  was  well  in  twenty- 
nine  days.  Berard  found  both  the  ovary  and  Fallopian  tube  in 
a  sac,  which  he  supposed  to  be  a  serous  cyst.  Having  opened  it, 
suppuration  ensued  and  the  patient  died. 

"  The  method  of  dealing  with  the  ovary  adopted  in  my  own 
case  was,  I  think,  justified  by  the  result,  and  in  similar  cases  I 
would  recommend  similar  treatment.  But  in  cases  in  which, 
from  long  continuance  of  the  strangulation,  or  excessive  tight- 
ness of  the  stricture,  the  tissues  of  the  ovary  either  are  or  are 
likely  to  become  gangrenous,  removal  of  the  organ  is,  in  my 
opinion,  the  proper  course  to  pursue." 

One  of  the  most  remarkable  cases  of  ovarian  hernia  is  the 
following,  narrated  by  Dr.  Leopold,  in  which  the  left  cornu  of 
the  uterus  was  included  in  the  protrusion,  and  removed  with  its 
corresponding  ovary. 


52  DISEASES   OF   THE   OVARIES. 

A  woman,  aged  twenty-eight,  the  issue  of  parents  who  had 
.had  seventeen  children  well  formed,  experienced  for  the  first 
time,  at  the  age  of  fourteen,  the  menstrual  molimen.  This  mo- 
limen  reappeared  regularly  every  twenty-six  or  twenty-eight 
days,  but  was  not  followed  by  any  loss.  It  was  accompanied 
with  pains  which  were  localized  in  the  left  inguinal  region, 
lasting  several  days.  In  process  of  time  the  patient  remarked 
that,  from  the  first  day  of  the  molimen,  a  body  of  the  size  of  a 
plum  rose  in  the  left  groin,  and  that  this  body  became  larger 
every  day,  and  only  resumed  its  former  volume  several  days 
after  the  period.  At  length  there  resulted  from  it  an  exces- 
sive irritability  and  a  grave  alteration  of  the  nervous  system. 
Married  at  twenty,  she,  with  the  advice  of  her  husband,  liad 
recourse  to  a  gynecologist,  who,  finding  the  vagina  absent,  en- 
deavored, by  incision  and  dilatation  with  tents,  to  form  a  pas- 
sage to  the  uterus,  in  order  to  remedy  a  supposed  retention  of 
the  menstrual  blood.  The  treatment  was  fortunately  interrupted, 
but  there  occurred  afterward,  and  especially  in  1877,  vicarious 
hemorrhages  from  the  nose  and  lungs. 

In  March,  1878,  she  placed  herself  under  the  care  of  Dr.  Leo- 
pold, who,  after  having  treated  her  for  more  than  twelve  months, 
published  this  remarkable  observation  : 

"  The  breasts,  pelvis  and  vulva  were  well  conformed,  but  the 
vagina  terminated  in  a  cul-de-sac  3  ctm.  in  depth.  In  this 
place  there  was  no  indication  of  a  vaginal  portion,  and  above 
there  was  no  trace  of  either  uterus  or  ovaries. 

In  the  left  groin,  on  a  level  with  the  external  inguinal  ring, 
was  perceived  an  uneven  tumor  of  about  the  size  of  half  a  hen's 
egg,  painful,  hardly  movable,  almost  on  a  parallel  in  its  great 
axis  with  the  inguinal  fold,  and  resembling  an  ovary  abnormally 
situated.  On  the  right  side  the  inguinal  region  was  normal ;  but 
on  deep  pressure  a  small  body  was  felt,  resembling  that  met 
with  on  the  left  side,  but  more  movable,  less  painful,  and  much 
smaller. 

The  pain  caused  by  the  tumor  on  the  left  side  became  at 
length  so  acute  that  an  operation  was  performed  on  February 
15,  1879.  The  tumor  was  removed.  It  was  not,  as  had  been  di- 
agnosed, a?i  ovary,  but  a  rudimentary  uterine  cornu.  At  the 
same  time  the  neighboring  tube  and  ovary  were  removed.  After 
the  abdominal  cavity  had  been  thoroughly  cleansed,  and  the 
ligatures  cut  short,  the  T-shaped  wound  was  closed  by  five  deep 
sutures  of  silver  wire,  inchiding  the  peritoneum,  and  by  several 
superficial  sutures  of  silk  thread,  and  at  the  point  of  union  of  the 
two  incisions  a  small  drainage-tube  was  introduced  to  a  depth  of 
about  one  centimetre. 


ERRORS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      53 

No  fever  followed,  and  fourteen  days  afterward  the  wound 
had  perfectly  healed.  The  time  of  the  menstrual  epoch  passed 
without  the  least  trouble,  only  that  there  were  some  contractions 
in  the  muscles  of  the  left  leg. 

The  amputated  cornu  uteri,  of  the  size  of  the  thumb,  pre- 
sented the  histological  structure  of  the  uterus  ;  tliat  is,  smooth 
fibres,  conjunctive  tissue,  vessels,  and  glands.  The  ovary  pre- 
sented all  the  characteristics  of  normal  structure,  with  yellow 
bodies  and  vesicles  at  various  stages  of  development.  The  tube 
has  a  pavilion  beautifully  fringed,  but  there  was  no  canal  con- 
tinuous with  the  infundibulum," 

Dr.  Alfred  Meadows  has  also  placed  upon  record,  in  the 
"Transactions  of  the  Obstetrical  Society"  (vol.  ii.),  a  case  in 
which  he  removed  a  hernial  ovary. 

I  have  also  met  with  a  very  singular  case  of  ovarian  displace- 
ment, where  the  condition  was  evidently  congenital,  and  was 
discovered  only  when  an  operation  had  to  be  performed  for  the 
removal  of  the  misplaced  ovary  on  account  of  cystic  degenera- 
tion. The  tumor  was  of  very  large  size,  and  for  its  removal  the 
usual  median  incision  was  made  between  the  umbilicus  and  the 
pubes.  No  difficulty  was  encountered  until  I  attempted  to  drag 
the  upper  part  down  through  the  incision,  when  I  found  a  broad 
band  of  union  extending  upward  from  the  umbilicus.  The  peri- 
toneum passed  from  the  abdominal  walls  on  to  the  tumor,  just 
as  it  does  on  to  the  rectum,  and  the  union  was  evidently  not 
merely  inflammatory  adhesion.  On  dividing  the  peritoneum,  I 
found  that  the  common  tendon  formed  part  of  the  cyst-wall,  and 
that  the  fibres  of  the  rectus  abdominis  muscle  were  inserted  into 
the  cyst.  The  round  ligament  of  the  liver  ran  through  the  cyst- 
wall  to  the  umbilicus,  and,  on  being  cut  through,  the  umbilical 
vein  contained  in  it  bled  profusely,  and  had  to  be  tied.  Very 
careful  dissection  had  to  be  made  to  remove  the  cyst,  and  when 
it  was  completed  it  was  found  that  a  large  triangular  gap  was 
left  in  the  abdominal  wall,  covered  only  by  skin,  and  having  its 
base  at  the  umbilicus  and  its  apex  at  the  xiphoid  cartilage. 
This  gap  was  closed  by  subcutaneous  stitches  of  silver  wire,  and 
the  patient  made  a  complete  recovery,  and  has  since  been  safely 
confined  of  a  living  child.  Careful  examination  of  the  tumor 
satisfied  me  that  the  only  explanation  which  could  possibly  be 
offered  of  these  unusual  conditions  was  that  the  ovary  had  be- 
come attached  to  the  cleft  in  the  visceral  arches  during  early 
embryonic  life,  and  had  subsequently  been  affected  by  cystic 
degeneration. 


54  DISEASES   OF   THE   OVARIES. 

Klob  has  described  a  twisting  of  the  ovary  on  its  axis,  which 
is  probably  congenital,  and  has  not  yet  been  found  to  be  of  any 
pathological  importance  in  an  otherwise  healthy  ovary.  In  the 
cystic  ovary  a  similar  twisting  has  been  observed  to  a  more 
complete  extent,  and  with  disastrous  results,  as  will  afterward 
be  described.  The  ovary  is  said  sometimes  to  be  completely  de- 
tached from  its  normal  position  and  relations,  and  forms  new 
attachments  elsewhere.  This  occurs  with  the  healthy  ovary, 
and,  as  Mr.  Spencer  Wells  has  shown,  also  probably  after  it  has 
undergone  degeneration.  How  and  when  it  occurs  have  not  yet 
been  satisfactorily  explained,  but  in  all  probability  the  curious 
axial  rotation  to  which  ovarian  tumors  are  subject,  as  described 
in  a  subsequent  chapter,  has  something  to  do  with  it. 

In  some  rare  instances  we  find  the  peritoneal  layers  so  defi- 
cient that  the  ordinary  mesenteries  and  ligamentous  folds  are 
completely  absent.  I  have  described  several  cases  of  congenital 
defects  of  the  peritoneum  {Dublin  Quarterly  Journal  of  Medical 
Science  for  February,  1869),  but  the  most  interesting  I  have  met 
with  is  one  I  published  in  the  Obstetrical  Journal  for  October, 
1876.  There  the  peritoneal  sac  was  wholly  absent,  the  intestines 
being  connected  together  by  an  abundance  of  extremely  loose 
cellular  tissue.  In  the  pelvis  it  was  absolutely  impossible,  on 
post-mortem  examination,  to  identify  any  organ  but  the  uterus, 
from  the  entire  absence  of  any  of  the  usual  peritoneal  limita- 
tions. Thus,  the  bladder  was  torn  open  in  removing  the  uterus, 
under  the  impression  that  it  was  some  of  the  loose  areolar  tissue, 
and  its  nature  was  recognized  only  by  the  escape  of  urine.  Two 
masses  close  to  the  uterus,  one  on  either  side,  when  cleared  of 
the  abundant  connective  tissue  and  laid  open,  proved  to  be  the 
ovaries,  and  in  the  left  there  was  the  clot  of  a  recent  Graafian 
follicle,  the  ovum  of  which,  if  it  ever  were  extruded,  must  have 
been  arrested  in  the  surrounding  tissue.  Over  the  right  ovary 
the  Fallopian  tube  seemed  to  course  in  a  normal  direction,  but 
it  became  lost  in  a  ma^s  of  connective  tissue,  and  I  could  find  no 
appearance  of  the  fimbriated  expansion.  On  the  left  side  there 
was  an  appearance  of  a  rudimentary  tube  in  a  fold  of  tissue. 

The  menstrual  history  of  the  patient,  as  ascertained  by  my 
friend  Dr.  Hickinbotham,  in  consultation  with  whom  I  saw  the 
patient  during  her  life,  was  in  no  way  abnormal,  and  she  was 
twenty-five  years  of  age.  The  cause  of  her  death  was  the  ob- 
struction of  scybalous  masses  in  a  bunch  of  coils  of  intestine, 
along  which  they  could  not  pass,  apparently  because  the  intes- 
tines were  unable  to  move  about. 

Another  class  of  remarkable  errors  of  development  of  the 
ovary  consists  of  those  to  which  I  have  given  the  name  of  by- 


ERRORS   OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      55 

pererchesis.  So  far  as  I  know,  they  are  limited  to  the  development 
of  fetal  structures  in  the  ovum  before  it  has  left  the  follicle,  this 
taking  place  probably  during  the  fetal  existence  of  the  ovary, 
and  constituting,  in  after-life,  the  variety  of  ovarian  tumor 
known  as  "  dermoid,"  under  which  head  this  remarkable  change 
will  be  found  fully  discussed.  They  are  also  seen  in  the  peculiar 
growths  resulting,  as  I  believe,  from  the  extended  life  of  ova 
which  have  been  dropped  out  of  the  follicle  into  the  peritoneal 
cavity,  and  there  have  continued  their  existence,  becoming  de- 
veloped into  huge  cysts,  instead  of  perishing,  as  they  usually 
do.  In  the  chapter  upon  ovarian  tumors  several  instances  of 
these  will  be  described. 

The  errors  of  development  of  the  Fallopian  tube  partake  very 
much  of  the  same  character  as  those  affecting  the  ovary.  When 
the  gland  is  insufficiently  developed,  its  tube  will  be  found  cor- 
respondingly defective.  I  have,  however,  already  narrated  a 
case  in  which,  coincident  with  defective  development  of  the 
peritoneum,  the  growth  of  the  tubes  had  been  apparently  ar- 
rested, while  the  ovaries  had  not  suffered  in  this  way.  Some- 
times, also,  we  find  the  tubes  are  displaced  by  congenital  defect, 
being  placed  either  too  low,  or  being  too  short,  or  having  their 
infundibula  too  small  to  enable  them  to  acquire  their  periodic 
relations  to  the  ovaries  properly,  and  in  these  cases  there  is  of 
necessity  a  resulting  sterility.  Conversely,  we  sometimes  find 
that  a  badly  developed  ovary,  or,  it  may  be,  an  ovary  which  has 
suffered  from  infiammation,  is  displaced  downward  and  out- 
ward, beyond  the  reach  of  the  normal  tube ;  and  here  again 
sterility  is  produced. 

In  some  instances  of  arrested  development  of  the  tubes  they 
are  found  to  be  occluded  at  both  ends,  and  distended  by  the 
fluid  into  cysts.  I  have  found,  in  several  instances,  that  this  oc- 
clusion at  the  outer  extremity  of  the  tube  was  formed  by  an  ad- 
hesion of  a  permanent  kind  to  the  inf undibulum  of  the  ovary, 
perhaps  of  a  congenital  origin,  but  more  probably  the  result  of 
inflammation.  In  these  cases  extreme  menstrual  pain  has 
resulted  from  periodic  distention  of  the  tubes,  the  patients 
have  been  sterile,  and,  when  married,  have  been  wholly  un- 
able to  perform  their  marital  functions.  They  have  wandered 
about  from  one  practitioner  to  another,  and  from  hospital  to 
hospital,  vainly  seeking  relief,  and  the  only  means  of  giving 
it  to  them  is  to  remove  the  ovaries  and  the  tubes.  Two  or 
three  characteristic  examples  of  this  condition  I  propose  here  to 
describe. 

Such  inflammatory  affections  as  spread  into  the  uterus  are 
apt  to  pass  along  the  tubes  and  produce  ovarian  or  peritoneal 


66  DISEASES   OF   THE   OVAKIES. 

mischief.  In  this  way  the  inflammation  of  the  tubes  is  of  im- 
mense importance,  and  it  may  be  suspected  after  the  appearance 
of  indications  of  the  more  serious  extension  of  the  disease.  It 
may  also  have  an  important  result,  in  addition  to  the  extension 
of  the  inflammation,  in  the  form  of  destructive  desquamation  of 
the  ciliated  epithelium  which  lines  the  tubes.  The  function  of 
this  ciliated  epithelium,  as  well  as  that  of  the  peristaltic  move- 
ments of  the  tubes,  is  evidently  chiefly  for  the  passage  down- 
ward of  the  ovum ;  but  it  also  seems  to  me  likely  that  it  is  to 
hinder  the  contact  of  the  spermatozoa  with  the  ovum  until  the 
latter  has  reached  the  cavity  suited  for  its  maturation.  The 
statement  that  impregnation  takes  place  before  the  ovum  has 
reached  the  true  uterus  seems  to  me  an  assumption  based  on  in- 
sufficient evidence — indeed,  on  no  evidence  at  all.  A  priori,  we 
may  safely  say  that,  if  it  is  the  rule.  Fallopian  pregnancies  and 
the  disasters  which  follow  them  ought  to  be  much  more  common 
than  they  are,  and  I  believe  it  to  be  more  than  likely  that  the 
real  cause  of  this  accident  is  the  coincidence  of  a  set  of  circum- 
stances, the  most  important  of  which  is  the  destruction  or  in- 
sufficiency of  the  ciliary  movement.  Inflammatory  desquama- 
tion may  then  be  a  cause,  and  probably  is  not  an  infrequent 
one,  of  tubal  pregnancy.  Destruction  of  the  tubal  epithelium 
may  also,  and  undoubtedly  often  does,  cause  atrophy  or  occlusion 
of  the  tubes,  and  occlusion  of  the  apertures  of  the  tubes  may  be 
the  cause  of  another  disease  of  the  tubes,  of  which  I  have  seen  a 
considerable  number  of  cases — dropsical  distention.  The  fact 
which  is  mentioned  by  many  authors,  that  both  tubes  are  usu- 
ally affected,  is  suggestive  that  tubal  dropsy  is  generally  the 
result  of  inflammatory  action.  The  distended  tubes  seldom  reach 
a  large  size,  and  the  majority  of  the  cases,  where  they  are  de- 
scribed as  having  reached  such  a  size  as  to  rival  and  demand 
the  treatment  of  ovarian  tumors,  are  open  to  the  suspicion  of 
inaccurate  description.  There  is,  however,  one  case  given  by 
Dr.  Peaslee  in  his  book  on  ovarian  tumors,  about  which  there 
can  be  no  doubt.  It  contained  eighteen  pounds  of  fluid,  and 
would  have  been  removed  if  the  patient  had  recovered  from  the 
tapping. 

In  some  six  or  seven  cases  where  I  have  found  the  Fallopian 
tubes  distended  with  fluid,  and  where  I  could  not  remove  them, 
I  have  drained  them  by  the  process  I  have  described  elsewhere 
as  applicable  to  cysts  of  the  liver  and  kidney  and  to  pelvic  ab- 
scesses, I  first  of  all  expose  the  cyst,  then  empty  it  by  the  aspi- 
rator, and  then  enlarge  the  opening  into  and  stitch  its  edges 
to  the  edges  of  the  parietal  wound  by  a  continuous  suture,  so 
as  completely  to  close  the  peritoneal  cavity.     The  cavity  of  the 


ERRORS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      57 

cyst  is  carefully  drained  in  front,  or  by  a  tube  passing  both  up- 
ward and  downward,  as  well  as  into  the  vagina,  I  have  in  this 
way  cured  cases  of  hydro-,  pyo-,  and  hsematosalpinx,  but  the 
results  and  the  rate  of  progress  are  not  nearly  so  satisfactory  as 
when  the  uterine  appendages  are  completely  removed. 

This  occlusion  of  the  Fallopian  tubes,  which  is  certainly  of 
very  frequent  occurrence,  is  facilitated  by  the  relations  of  the 
infundibulum  to  the  ovary,  this  being  far  more  intimate  than  is 
generally  imagined.  Fig.  1  (p.  4)  gives  a  perfectly  exact  repre- 
sentation of  the  organs,  but  in  order  to  display  them  their  rela- 
tions have  been  destroyed,  for  the  fimbriae  are  always  in  close 
relation  to  the  ovary,  and  the  tubes,  as  I  have  said,  curl  over  and 
around  the  ovary,  so  that  the  infundibulum  is  in  contact  with  the 
lower  and  posterior  surface  of  the  ovary,  the  axis  of  which  is 
often  nearly  vertical  generally,  but  not  alwaj^s.  Adhesion,  as  I 
have  said,  occurs  at  the  menstrual  periods  independently  of  ovu- 
lation, and  I  think  it  more  than  probable  that  not  more  than  one 
in  ten  of  the  ova  shed  by  the  glands  really  enter  the  tubes.  The 
rest  drop  into  the  peritoneum  and  die  there. 

The  largest  collection  of  fluid  which  I  have  seen  in  an  oc- 
cluded Fallopian  tube  occurred  in  the  following  case,  the  more 
remarkable  in  that  the  disease  was  unilateral. 

E.  E.  T ,  aged  twenty-eight,  was  placed  under  my  care  by 

Mr.  Watkin  Williams,  of  this  town.  She  had  been  married,  but 
had  been  obliged  to  divorce  her  husband  for  misconduct.  It  is 
more  than  probable  that  gonorrhoea  had  been  communicated  to 
her  about  five  years  before  I  saw  her.  From  that  date  she  had 
suffered  from  intense  pain  during  the  menstrual  period,  and  had 
become  very  much  emaciated.  She  had  been  under  a  great  many 
doctors  without  obtaining  relief.  I  discovered  a  small  cystic  tu- 
mor behind  and  to  the  right  of  the  uterus,  freely  movable,  but 
very  painful  when  moved.  I  advised  its  removal,  and  this  I  un- 
dertook on  May  23,  1879.  I  found  it  to  consist  of  the  right  Fallo- 
pian tube,  distended  by  about  a  pint  of  clear  serum.  The  infun- 
dibulum was  glued  on  to  the  right  ovary,  and  the  uterine  part 
of  the  tube  was  distended  like  a  tortuous  sausage,  the  greater 
part  of  the  cyst  being  made  from  the  outer  half  of  the  tube. 
I  removed  the  tube  and  left  the  ovary.  She  made  an  easy 
recovery,  is  now  in  robust  and  perfect  health,  and  has  married 
again. 

Dr.  Saundby  examined  the  fluid  removed,  and  gave  me  the  fol- 
lowing report  upon  it :  specific  gravity,  1014  ;  reaction  alkaline, 
pale  greenish  color,  clear,  with  scanty  grayish  deposit ;  contains 
about  three-fifths  of  its  volume  of  an  albuminous  body,  having 


58  DISEASES   OF  THE   OVARIES. 

all  the  characters  of  serum-albumen.  After  removing  the  albu- 
men, the  filtrate  precipitates  with  mercuric  nitrate  (urea  ?)  and 
with  argentic  nitrate  (chloride  of  sodium  ?).  The  microscopical 
examination  showed  only  a  few  indifferent  cells. 

E,  C ,  aged  thirty -two,  was  married  at  seventeen  years  of 

age,  and  had  her  first  child  when  she  was  eighteen,  and  her 
second  in  the  following  year.  She  was  quite  well  until  1870, 
when  she  had  a  smart  attack  of  inflammation  of  the  pelvis,  and 
ever  after  that  she  had  extreme  pain  at  her  periods,  when  she 
had  to  remain  in  bed  for  several  days  ;  and  she  described  her 
sufferings  as  amounting  to  agony,  and  resembling  labor-pains 
more  than  anything  that  she  knew  of.  She  was  seldom  free 
from  pain  in  the  back,  and  for  the  last  three  years  she  has  been 
utterly  unable  to  endure  married  life.  I  found  the  uterus 
slightly  retroverted,  and  on  each  side  of  it  there  was  a  distinct 
mass  in  the  position  of  the  ovary,  large,  fixed,  and  extremely 
tender.  She  had  been  under  a  great  variety  of  treatments,  with- 
out the  slightest  benefit.  On  October  5,  1880,  I  made  an  explora- 
tory incision,  and  found  both  ovaries  adherent  in  the  cul-de-sac, 
tlie  infundibula  of  both  tubes  occluded,  and  the  tubes  themselves 
distended  into  cysts.  The  whole  of  the  organs  were  matted  to- 
gether, and  the  operation  for  their  complete  removal  was  ex- 
tremely difficult.  The  amount  of  fluid  in  each  tube  was  about 
two  ounces.  She  made  an  uninterrupted  recovery  from  the 
operation  until  the  monthly  period  after,  at  which  time  she  had 
a  small  hsematocele  on  the  right  side,  coincident  with  a  slight 
menstrual  appearance.  From  this,  however,  she  speedily  re- 
covered, and  on  February  17th  last  I  found  the  uterus  per- 
fectly free  and  normal  in  direction.  I  last  saw  her  on  March 
26th,  and  found  her  in  perfect  health,  absolutely  free  from  pain, 
and  she  told  me  that  she  had  seen  no  appearance  of  menstrua- 
tion since  November,  and  that  marital  functions  had  been  re- 
sumed without  the  slightest  pain. 

H.   S ,  aged  thirty-seven,   had   been  married  seventeen 

years,  and  had  only  one  child,  fifteen  years  ago.  She  did  not 
recover  well  from  that  confinement,  and  ever  since  had  men- 
struated too  often  and  too  profusely,  being  rarely  a  fortnight 
clear.  I  found  the  fundus  large  and  tender,  somewhat  ante- 
verted,  and  what  I  regarded  as  the  ovaries  formed  two  large 
masses  low  down,  and  somewhat  behind  the  uterus.  For  a  long 
time  past  sexual  intercourse  had  been  quite  impossible  on  ac- 
count of  the  suffering  it  caused  her.  Dr.  C.  H.  Phillips,  of  Han- 
ley,  who  placed  her  under  my  care,  had  exercised  a  large  amount 


ERRORS   OF   DEVELOPMENT   OF   OVARIES   AND    OVIDUCTS.      59 

of  ingenuity  in  her  treatment,  without  any  benefit,  and  from 
February  till  August,  1«80,  we  conducted  further  treatment 
equally  in  vain.  On  August  3d  I  opened  the  abdomen,  and 
found  the  ovaries  large,  completely  adherent  in  the  cul-de-sac, 
covered  with  lymph,  and  having  the  infundibula  of  the  tubes 
occluded.  The  tubes  were  distended  into  large  cysts,  each  con- 
taining from  four  to  five  ounces  of  clear  serum.  The  organs 
had  to  be  very  carefully  detached,  as  the  adhesions  were  ex- 
tremely firm,  and  the  hemorrhage  during  the  operation  was 
tolerably  profuse.  Her  recovery  from  the  operation  was  rapid 
and  easy,  and  the  only  distresses  she  encountered  were  the  cli- 
macteric flushings.  In  May  last  Dr.  Phillips  sent  me  a  most 
satisfactory  account  of  her  condition. 

A.  S ,  aged  thirty-eight,  had  been  twice  married,  and  had 

had  five  children  by  her  first  husband,  the  youngest  being  twelve 
years  of  age.  She  has  had  no  children  by  the  second  husband, 
to  whom  she  has  been  married  six  years.     After  her  second 


Fig.  19. — Bilateral  hydrosalpin 
uterus  ;  6,  vagina  ;  c,  os  uteri ;  d  i 


(  r 
1  f  i 


Arthur  Farre,  Encyc.  Anat.  and  Physiol.):  a, 
e,  ovary. 


marriage  she  seems  to  have  had  an  attack  of  pelvic  inflamma- 
tion, and  ever  since  she  has  had  intense  pain  at  her  periods. 
She  referiel  this  pain  distinctly  to  the  region  of  the  ovaries. 
For  somewhere  about  three  years  she  had  been  wholly  unable  to 
submit  to  intercourse,  and  her  domestic  life  was  thereby  ren- 
dered extremely  uncomfortable.  I  found  the  uterus  to  be  normal 
in  position,  and  on  each  side  of  it  I  found  a  mass  situated  quite 
low  down,  and  having  characteristics  exactly  like  those  in  the 
two  cases  given  above,  so  that  I  had  no  hesitation  in  making  up 


60 


DISEASES   OF   THE   OVARIES. 


Fig.  20. — Occluded  and  adherent  Fallopian  tubes  (Arthur  Farre,  after  Hooper) :    a,  uterus ;  6,  Fallopian 
tubes ;  d,  d,  ovaries  ;  e,  e,  bands  of  adhesion. 


Fig.  21.— Kipht  (A)  and  left  fB)  Fallopian  Tubes  and  Ovaries,  removed  by  abdominal  Bection  from  a 
patient  aged  thirty,  who  had  Ruffcrod  rarly  in  hor  marriod  life  from  gOTiorrhcva.  The  large  bulbous  mn«Rt'S 
are  the  Fallopian  tubts  occluded  and  dihtendcd  with  serum  thydrosiilpinx),  the  shrivelled  ovaries  being 
Bliown  in  the  convexity  of  the  tubes.  (From  a  photograph  slightly  reduced.  Preparation  now  in  Museum 
of  Boyal  College  of  Surgeons.) 


EEROKS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      Gl 

my  mind  that  she  had  occlusion  and  distention  of  the  tubes. 
Dr.  Cameron,  of  Bilston,  who  had  placed  her  under  my  care,  sent 
her  to  me  with  a  statement  to  the  effect  that  he  was  perfectly 
sure  that  nothing  but  an  operation  would  relieve  her.  This  I 
performed  upon  May  21st,  and  found  matters  exactly  as  described 
in  the  last  case.  Her  recovery  was  rapid,  and  the  relief  imme- 
diate and  complete. 

In  some  cases  we  find  that  the  contents  of  these  closed  tubes 
consist  of  pus  or  menstrual  fluid,  both  of  which  I  can  instance 
from  my  experience  in  the  following  cases. 

Mrs.  L ,  aged  thirty-four,  was  sent  to  me  by  Dr.  McLinc- 

tock,  of  Church  Stretton,  in  September,  1878.  She  had  been 
married  four  and  a  half  years,  and  had  one  child.  Since  her 
confinement  she  had  never  been  well,  and  had  suffered  from 
symptoms  which  clearly  were  those  of  subinvolution  and  retro- 
flexion. She  had  profuse  menstruation,  and  on  consulting  a  phy- 
sician, in  July,  1872,  she  was  told  she  had  a  tumor  behind  the 
womb,  and  that  the  womb  must  be  dilated  and  the  tumor  re- 
moved. For  this  purpose  a  sponge-tent  was  introduced,  and 
inadvertently  left  in,  according  to  her  reiterated  statement,  for 
nine  days.  She  had  suffered  from  an  attack  of  "acute  inflamma- 
tion of  the  bowels,  and  was  in  her  bed  for  seven  weeks."  This 
incident  occurred,  I  am  pleased  to  say,  neither  in  Church  Stret- 
ton nor  in  Birmingham.  "When  she  came  to  me  on  September  24, 
1878,  she  was  in  a  wretched  state  of  exhaustion  and  emaciation. 
I  found  a  mass  on  the  right  side  of  the  uterus,  which  fluctuated 
indistinctly.  The  uterus  was  retroflexed  and  fixed  completely  by 
perimetric  effusion.  I  tapped  the  mass,  and  removed  about  four 
ounces  of  pus  from  what  I  now  know  was  an  abscess  of  the  right 
ovary.  She  was  much  relieved,  and  returned  to  Church  Stretton 
under  Dr.  McLinctock's  care,  and  slowly  gained  some  strength. 
She  did  not  make  anything  like  a  recovery,  however,  and  her 
medical  attendant  sent  her  back  several  times  to  me,  and  to- 
gether we  carried  on  a  variety  of  treatment,  without  much  bene- 
fit. The  uterus  remained  fixed,  and  all  efforts  to  replace  it  were 
so  painful  that  she  could  not  endure  them.  She  could  not  bear 
intercourse,  and  she  never  was  a  day  without  pain,  and  her  life 
was  fitly  described  as  a  burden  to  herself  and  her  relatives. 

Dr.  McLinctock  sent  her  down  to  me  again  at  the  end  of  last 
February,  and  in  his  letter  he  told  me  he  was  sure  something 
more  must  be  done  if  our  patient's  life  was  to  be  saved.  I  found 
that  the  mass  on  the  right  of  the  uterus  was  just  as  I  had  left  it, 
that  the  uterus  was  still  fixed  and  retroflexed,  that  there  was 
now  a  more  clearly  defined  mass  to  the  left  of  the  uterus,  and 


62  DISEASES   OF   THE   OVARIES. 

that  the  whole  roof  of  the  pelvis  was  exquisitely  tender  to  the 
touch.  Her  temperature  went  up  at  night,  and  she  had  night- 
sweats:  and  although  I  could  feel  no  fluctuation,  I  had  no  doubt 
there  was  pus  somewhere.  I  therefore  advised  and  performed 
an  exploratory  incision  on  March  Gth.  I  found  the  pelvis  roofed 
over  by  adherent  coils  of  intestine,  which  I  lifted  with  much 
trouble.  Below  this  the  whole  of  the  organs  were  matted  to- 
gether, and  their  identification  was  a  matter  of  the  greatest  dif- 
ficulty. Finally,  I  succeeded  in  recognizing  the  right  Fallopian 
tube,  distended  into  a  cyst  with  greatly  thickened  walls,  and 
full  of  pus.  Below  it,  and  intimately  adherent  to  it,  lay  the 
ovary,  as  large  as  an  orange,  and  containing  some  old  cheesy 
matter,  the  remains,  probably,  of  the  abscess  which  I  tapped 
two  and  a  half  years  before.  The  uterus  was  bound  down  in  the 
cul-de-sac  by  old  adhesions,  and  from  these  I  relieved  it.  I 
found  the  left  ovary  adherent  below  the  fundus,  and  from  it  the 
left  Fallopian  tube  ran  a  circuitous  course,  like  a  sausage  in  ap- 
pearance, and  adherent  to  the  brim  of  the  pelvis,  the  uterus,  and 
a  piece  of  small  intestine.  It  contained  about  two  ounces  of  pus. 
I  removed  both  ovaries  and  both  tubes,  cutting  the  latter  off 
close  to  their  uterine  attachments.  The  hemorrhage  during  the 
operation  was  very  troublesome,  but  w-as  controlled  by  sponge- 
pressure.  Mr.  J.  Raffles  Harmar  assisted  me,  and  Mr.  Wright 
Wilson  gave  ether. 

The  patient  has  recovered  without  a  bad  symptom,  and  is 
perfectly  free  from  pain  for  the  first  time  since  the  incident  of 
the  sponge-tent.  The  uterus  is  now  perfectly  free,  and  any 
movement  of  it  gives  her  no  pain.  My  only  regret  about  this 
case  is  that  I  did  not  operate  two  years  before. 

J.  H ,  aged  thirty-one,  came  under  my  care  in  April  last, 

nfter  having  been  under  the  treatment  of  many  well-known 
practitioners.  There  was  no  history  of  any  acute  illness,  but  for 
many  months  she  hacl  been  ailing,  unable  to  walk,  and  con- 
stantly in  pain,  and  her  sufferings  during  the  menstrual  week 
were  very  great.  Slie  was  desirous  of  getting  married,  but,  as 
she  was  quite  unable  to  get  about,  this  was  out  of  the  question. 
She  had  been  told  by  all  her  doctors  that  she  suffered  from  a 
displaced  womb.  On  either  side  of  the  uterus  was  a  large,  fixed 
mass,  the  slightest  pressure  on  which  produced  pain  of  a  sicken- 
ing kind.  No  fluctuation  could  bo  determined.  She  used  iodine 
blisters  and  took  bromide  of  potash  for  two  months,  without  any 
benefit.  At  the  end  of  June  I  proposed  an  abdominal  section, 
but  only  with  the  result  that  she  consulted  another  practitioner, 
greatly  my  senior,  and  under  whose  care  she  had  previously 


ERROnS   OF   DEVELOPMENT   OF   0VARIE3   AND    OVIDUCTS.       C;-> 

been,  who  told  her  that  she  ought  never  to  submit  to  any  such 
proposal. 

She  came  back  to  me,  however,  in  August,  and  I  took  advan- 
tage of  the  presence  of  Dr.  Battey  in  my  house  as  a  guest  to  get  his 
advice.  He  agreed  with  me  that  it  was  a  case  urgently  demand- 
ing interference.  This  induced  her  friends  to  take  her  to  an  emi- 
nent specialist  at  a  distance,  who  characterized  my  proposal  as 
absurd  ;  but  yet  the  poor  girl  got  no  better,  and  she  returned  to 
me  on  October  18th,  determined  to  have  the  operation  performed. 

One  matter  of  importance  was  the  question  of  her  affianced 
husband's  knowledge  and  consent,  and  this  I  desired  should  be 
secured.  For  that  purpose  I  had  an  interview  with  him,  and 
fully  explained  the  case  and  my  proposed  treatment.  He  raised 
not  the  slightest  objection,  and  expressed  himself  as  desirous 
only  of  obtaining  relief  for  his  fiancee.  The  operation  was  per- 
formed on  October  21st,  and  I  found  the  pelvic  organs  completely 
matted  together.  After  I  had  separated  them — a  matter  of  great 
difficulty,  taking  a  long  time  in  its  performance — I  found  the  left 
Fallopian  tube  distended  and  as  big  as  an  orange.  Unfortu- 
nately it  burst,  and  the  curdy  pus  with  which  it  was  filled  was 
scattered  into  the  peritoneum  ;  and  a  similar  misfortune  occurred 
in  the  removal  of  the  right  tube,  which  was  also  distended  with 
pus.  I  need  not  say  that  I  took  every  care  to  cleanse  the  pelvis 
well  out,  and  I  used  a  drainage-tube.  The  removal  of  the  tubes 
and  ovaries  in  this  case  constituted  the  most  protracted  and 
difficult  operation  I  have  ever  performed.  The  patient  recovered 
speedily  and  completely,  has  not  menstruated,  and  is  completely 
free  from  pain. 

At  the  meeting  of  the  Societe  Anatomique,  held  on  January 
16,  1880,  a  case  of  pyosalpinx  was  narrated  from  Dr.  Bernutz's 
service  at  La  Charite.  The  patient  was  aged  twenty-nine,  and 
was  admitted  with  very  severe  symptoms,  pointing  to  pelvic  in- 
flammation, and  subsequently,  peritonitis.  She  died  four  days 
after  admission,  and,  on  a  post-mortem  examination,  suppura- 
tive peritonitis  was  found  to  have  spread  up  from  the  pelvis, 
having  arisen  from  the  rupture  of  a  tubal  abscess.  The  follow- 
ing is  a  description  of  the  parts  : 

"  The  tubes  extended  one  on  either  side,  and  were  the  seat  of 
the  principal  alterations.  The  internal  half  of  each  tube  was 
healthy,  and  its  direction  normal,  but  the  outer  half  presented 
three  or  four  dilatations,  varying  in  size,  the  largest  being  situ- 
ated at  the  outer  extremity,  being  formed  by  the  occlusion  of  the 
pavilion,  so  that  there  was  no  opening  into  the  tube,  which  was 
distended  with  pus.     These  dilatations  communicated  one  with 


64  DISEASES   OF   THE   OVARIES. 

another,  and  the  internal  mucous  surface  was  smooth  and 
softened,  but  otherwise  normal.  There  was  no  communication 
between  the  uterus  and  the  tubes.  The  ovaries  did  not  occupy 
their  usual  situation,  being  both  displaced  downward  and  em- 
braced by  the  concavity  of  the  tube,  making  with  this  a  largish 
mass.  On  the  left  side  there  was  a  peculiar  arrangement ;  a  cyst 
occupied  the  pavilion  of  the  tube,  of  the  size  of  a  hen's  egg,  which 
seemed  to  be  directly  continuous  with  the  cavity  of  the  ovary, 
and  the  two  cysts  were  entirely  empty.  The  internal  surface  of 
the  tube  was  smooth,  while  that  of  the  ovary  was  very  rough 
and  much  reddened,  the  difference  being  distinctly  marked  by 
a  line  of  division  of  the  two  structures.  The  ovary  was  not 
greatly  enlarged,  and  upon  its  posterior  surface,  toward  the  mid- 
dle, was  found  a  small  rupture  through  which  the  contents  had 
been  extra vasated  into  the  peritoneum." 

M.  Bernutz  remarks  that  in  all  probability  the  suppuration  of 
the  tubes  and  left  ovary  was  of  ancient  date,  and  that  the  fatal 
peritonitis  was  undoubtedly  due  to  the  perforation  of  the  abscess 
into  the  peritoneum.  He  does  not  give  any  explanation  or  his- 
tory of  the  pyosalpinx.  The  case,  however,  is  to  me  an  extremely 
interesting  one,  for  it  illustrates  exactly  the  same  conditions  as 
those  seen  in  the  case  narrated  above,  and  I  think  there  is  little 
reason  to  doubt  that,  if  the  patient  had  been  seen  earUer  in  her 
history,  the  symptoms  would  have  been  found  sufficiently  severe 
to  warrant  an  abdominal  section;  and,  if  that  had  been  done  be- 
fore the  rupture,  not  only  would  the  patient's  life  have  been  saved, 
but  her  disease  would  have  been  cured.  Even  after  the  rupture 
of  the  cyst  and  the  onset  of  peritonitis,  had  the  case  been  under 
my  care,  I  would  have  opened  the  abdomen  without  the  slightest 
hesitation,  have  cleaned  out  the  cavity,  and  removed  the  cause 
of  the  disease.  I  have  had  numerous  cases  in  my  recent  prac- 
tice where  such  a  proceeding — which  would  have  been  regarded 
as  madness  three  years  ago — has  had  the  most  brilliantly  suc- 
cessful results. 

As  another  instance  of  pyo-salpinx,  I  may  give  the  following: 

M.  F ,  aged  twenty-six,  had  been,  ever  since  the  age  of 

seventeen,  living  an  immoral  life.  About  three  years  ago  she 
suffered  from  gonorrhoea,  which  was  followed  by  severe  pelvic 
inflammation,  and  ever  since  that  time  she  had  suffered  from 
severe  menstrual  pain.  About  six  weeks  previous  to  my  seeing 
her  sh6  had  been  exposed  for  a  whole  night  to  extreme  cold,  and 
after  that  suffered  from  great  pelvic  pain.  She  was  placed  under 
my  care  in  March  last,  by  Mr.  John  Green,  of  this  town.  I  found 
her  suffering  from  all  the  symptoms  of  pelvic  suppuration,  and 


EKKOllS    OF    DEVELOPMEXT    OF    OVAUIES    AND    OVIDUCTS.       «),"> 

there  was  a  fluctuating  pelvic  tumor  on  the  left  side  of  the  ute- 
rus, this  I  diagnosed  to  be  the  left  Fallopian  tube  distended 
with  pus.  I  opened  the  abdomen  on  March  2.Sth,  and  found  my 
diagnosis  correct.  It  was,  however,  quite  impossible  to  remove 
the  tube,  and  I  therefore  had  to  content  myself  with  emptying 
it,  dragging  it  up  to  the  wound,  securing  the  two  openings  to- 
gether by  a  continuous  suture,  and  fastening  in  a  drainage-tube. 
This  was  kept  in  for  some  weeks,  and  she  made  a  satisfactory 
recovery.  Her  menstrual  suffering,  however,  is  quite  unrelieved, 
and  therefore  the  cure  is  only  partial.  It  could  only  have  been 
made  complete  by  the  removal  of  both  tubes  and  ovaries,  but 
this  was  made  quite  impossible  by  the  dense  adhesions  formed 
by  the  previous  inflammation.  In  such  a  case,  of  course,  there 
is  not  the  slightest  hope  of  her  ever  becoming  a  mother,  though, 
as  she  has  left  her  irregular  life  and  has  been  married  for  about 
a  year,  this  would  be  desirable.  As  it  is,  she  will  certainly  re- 
main a  sufferer  until  she  reaches  the  climacteric. 

A  few  days  ago  I  operated  on  a  patient  sent  to  me  by  Dr. 
Standish,  of  Cradley,  on  account  of  persistent  pelvic  pain,  greatly 
aggravated  at  each  period,  and  which  no  treatment  relieved.  I 
could  find  nothing  on  examination,  and  I  had  very  great  mis- 
givings about  operating  in  a  case  where  the  conditions  were 
purely  subjective.  I  opened  the  abdomen,  however,  and  found 
both  ovaries  and  tubes  adherent.  The  tubes  were  occluded,  and 
the  outer  extremity  of  each  was  occupied  by  a  small  chronic 
abscess,  which  amply  accounted  for  all  the  symptoms.  The 
preparations  are  now  in  the  museum  of  the  College  of  Surgeons. 
The  patient  has  made  an  excellent  recovery. 

The  features  common  to  these  cases  are  (1)  n,  history  of  severe 
pelvic  inflammation,  though  sometimes  this  cannot  be  ascer- 
tained with  precision.  Its  origin  is  variously  ascribed  as  from 
gonorrhoea,  a  chill,  or  sudden  stoppage  of  menstruation,  and 
(most  frequently)  inflammation  after  labor  or  a  miscarriage. 
There  is  always  (2)  pain,  which  comes  on  after  exertion,  and 
especially  after  intercourse,  and  generally  becomes  intensified 
when  menstruation  appears.  At  this  time  the  pain  ,is  often 
described  as  excruciating,  and  it  lasts  throughout  the  period.  In 
the  majority  of  instances  there  is  (3)  irregular  and  profuse  men- 
struation, often  amounting  to  hemorrhage. 

The  physical  signs  are  (1)  swellings  at  the  seat  of  the  ovaries, 
which  are  always  tender  and  generally  quite  fixed.  Distinct 
fluctuation  can  often  be  felt,  and  their  peculiar  sausage-like 
shape  has  frequently  enabled  me  to  diagnose  correctly  the  con- 
dition previous  to  the  operation, 
5 


06  DISEASES   OF   THE   OVARIES. 

Xo  treatment  whatever  relieves  these  cases,  save  removal  of 
the  uterine  appendages. 

Most  of  my  cases  had  been  in  the  hands  of  some  of  our  most 
eminent  specialists  before  they  came  to  me,  and  an  infinite  va- 
riety of  treatments,  both  by  drug  and  operation,  had  been  used 
fruitlessly.  They  had  all  been  treated  by  pessaries,  and  many 
of  them  had  had  their  cervical  canals  dilated  and  cut. 

Tapping  the  dilated  tubes  is  of  no  use  and  is  extremely  diffi- 
cult. 

At  the  operation  the  organs  are  nearly  always  found  matted 
to  the  pelvic  wall  and  to  intestines,  and  their  removal  is  often 
extremely  difficult — far  more  difficult  than  removal  of  an  ova- 
rian cystoma.  I  always  remove  the  ovaries  along  with  the 
tubes,  as  without  the  ducts  the  glands  are,  of  course,  useless. 

All  my  patients — twenty-two  in  number — have  recovered,  and 
of  those  in  which  a  sufficient  time  has  elapsed  since  the  oper- 
ation I  can  say  confidently  that  they  are  all  completely  cured. 

All  the  cases  had  been,  of  course,  rendered  sterile  by  the  dis- 
ease, and  in  most  of  them  the  marital  function  was  also  de- 
stroyed. I  have  not  found  that  the  operation  has  had  any  other 
effect  than  that  of  restoration  of  sexual  activity  where  it  has 
been  lost. 

Menstruation  has,  in  most  cases,  been  arrested  immediately, 
but  in  a  few  it  has  lingered  for  a  month  or  tAvo. 

The  pathological  condition  of  most  importance  is  practically 
the  same  in  all  these  cases,  and  arises,  I  think,  from  an  attack 
of  acute  or  subacute  oophoritis  or  peri-oophoritis.  During  this 
process  the  trumpet-shaped  extremity  of  the  tube  approaches 
the  ovary  for  its  normal  temporary  attachment ;  and  this,  by  the 
inflammator}'  process,  becomes  permanent.  Certain  it  is  that, 
in  nearly  all  the  cases,  permanent  attachment  of  the  tube  to  the 
ovary  is  to  be  seen.  Probably,  after  the  attachment  has  occurred, 
the  inflammatory  process  extends  to  the  tubes,  there  is  a  desqua- 
mation of  the  ciliated  epithelium,  and  occlusion  of  the  tube  at  its 
uterine  extremity  occurs. 

The  nature  of  the  contents  of  the  tube  is  determined  by  causes 
which  I  (lo  not  understand.  The  most  common  of  the  varieties 
of  this  disease  is  hydrosalpinx,  and  the  rarest  is  haematosalpinx. 

In  connection  Avith  these  cases  I  may  refer  to  a  curious  series 
of  i^henomena  which  has  repeatedly  fallen  under  my  notice, 
and  which,  I  gather  from  the  writings  of  other  observers,  has 
also  been  noticed  by  them.  Thus,  in  several  cases  where  I  have 
opened  the  abdomen  for  the  purpose  of  removal  of  the  ovaries 
on  account  of  severe  and  intractable  pelvic  pain,  I  found  the 
organs  matted  together  with  all  the  appearances  of  old  pelvic 


ERRORS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.       G7 

peritonitis— SO  much  so  that  I  have  been  unable  to  complete  the 
operation.  I  have  also,  as  I  have  already  stated,  found  in  very 
many  instances  the  Fallopian  tubes  occluded  and  distended  with 
fluid  which,  in  several  cases,  was  purulent.  Looking  back 
upon  the  histories  given  by  some  of  the  patients  in  whom  I  wa^ 
unable  to  complete  the  operation,  I  have  found  distinct  state- 
ments made  of  recurrent  attacks  of  severe  pelvic  inflammation. 
I  have  also  noted,  in  some  of  them  who  had  been  under  my  care 
for  prolonged  periods,  that  at  some  of  my  examinations  I  found 
distinct  tumors  on  one  or  both  sides  of  the  uterus,  while  at  other 
examinations  no  trace  of  these  tumors  could  be  seen.  Speaking 
of  an  absolutely  similar  experience,  Dr.  Mathews  Duncan  says  : 
"After  a  time  the  tumor  disappears.  Frequently  its  disappear- 
ance is  accompanied  by  adhesive  perimetritis.  Now,  what  has 
happened  in  these  cases  ?  Of  course  it  may  be  said  that  it  is  a 
case  of  mere  ignorance,  or  that  the  cysts  were  parovarian  ;  but, 
to  this  latter  explanation  there  is,  for  me,  the  great  objection 
that  the  cases  occur  more  frequently  by  far  than  to  admit  of 
their  being  justly  so  explained.  We  must  suppose,  therefore, 
the  bursting  of  the  not  infrequent  small  follicular  dropsies.  I 
would  further  add  that  the  bursting  of  simple  parovarian  cysts 
does  not  appear  to  me  to  be  followed  by  perimetritis,  or  accom- 
panied by  it,  so  generally  in  the  case  of  the  disease  of  which  I 
have  been  speaking." 

In  only  one  of  my  cases  have  I  seen  reason  to  accept  Dr.  Dun- 
can's explanation,  that  is  to  say,  in  only  one  of  them  have  I  found " 
the  small  cyst  of  the  ovary  (which  was  probably  on  the  point  of 
bursting),  and  elsewhere  in  the  ovaries,  distinct  evidence  that 
similar  ruptures  had  occurred  before.  I  feel  perfectly  certain 
that  in  some  of  the  cases  there  can  be  no  doubt  that  Dr.  Dun- 
can's explanation  is  the  correct  one  ;  but  I  have  so  much  more 
frequently  found  the  Fallopian  tubes  at  fault,  that  I  am  inclined 
to  believe  that  in  the  great  majority  of  these  cases  of  recurrent 
pelvic  peritonitis,  due  to  rupture  of  a  cyst,  it  is  in  the  tubes  that 
we  shall  find  the  origin  of  the  mischief. 

Looking  at  some  of  my  preparations  of  hydro-  and  pyosal- 
pinx,  I  find  it  difficult  to  resist  the  conclusion  that  periodic  rup- 
ture of  the  distended  infundibulum  is  a  somewhat  frequent 
occurrence  in  them.  It  is,  of  course,  very  likely  that  in  many 
cases  a  cure  is  effected  in  this  way  ;  but  in  others  the  disease  is 
only  aggravated,  and  probably  in  many  the  rupture  is  fatal.  In 
a  discussion  which  took  place  at  a  meeting  of  the  American 
Gynecological  Society  in  1880, 1  find  a  corroboration  of  my  views 
in  some  of  the  remarks  of  my  friend.  Dr.  James  R.  Chadwick,  of 
Boston.     He  speaks  as  follows  :  "•ISrow  I  have  had  several  cases 


C8  DISEASES    OF   THE   OVARIES. 

presenting  a  similar  succession  of  symptoms,  in  which  I  have 
been  able  to  detect  a  cyst  on  one  side  or  the  other  of  the  uterus, 
which  I  have  diagnosticated  as  a  cyst  of  the  Fallopian  tube,  but 
have  never  verified  my  opinion  by  operation  or  autopsy.  My 
explanation  of  the  symptom  is  this  :  that  fluid  collects  in  the 
tubes,  of  which  the  fimbriated  end  is  occluded  until  it  is  greatly 
distended  ;  as  the  monthly  period  approaches,  peristaltic  action 
repeatedly  occurs  in  the  tube,  attended  with  great  pain,  which 
tends  to  expel  the  fluid  through  the  uterine  end  temporarih^  oc- 
cluded. This  action  continues  at  intervals  with  increasing  vio- 
lence, until,  during  the  catamenial  relaxation  of  the  uterus,  the 
fluid  contents  of  the  tube  are  forced  through  the  opening  into  the 
uterine  cavity,  with  immediate  relief.  If  this  view  be  correct, 
the  removal  of  the  ovaries  was  of  no  consequence,  though  the 
operation  was  quite  as  urgently  called  for.  as  the  best  and  per- 
haps the  only  means  of  relieving  the  cystic  condition  of  the 
tubes,  and  securing  to  the  patient  immunity  from  her  suffering."* 

A  patient  who  had  been  under  my  care  for  some  months  died 
suddenly  a  few  weeks  ago.  and  the  pelvic  organs  were  obtained  at 
the  post-mortem  examination.  She  came  under  my  care  in  Jan- 
uary last,  as  an  out-patient  at  the  Women's  Hospital,  with  symp- 
toms of  chronic  metritis,  including  severe  menorrhagia.  On 
April  28th  I  recognized  the  presence  of  a  small  cyst  on  the  right 
side,  as  large  as  an  orange.  At  the  end  of  May  she  had  an  attack 
of  pelvic  peritonitis.  On  Jime  13th  the  tumor  had  disappeared. 
On  August  loth  it  had  returned,  and  it  again  disappeared  in 
September,  its  disappearance  being  accompanied  by  inflamma- 
tory symptoms.  On  October  10th  it  was  again  to  be  felt,  and 
about  the  OOth  she  died,  and  Mr.  J.  Garman,  of  Wednesbury,  ob- 
tained the  preparation  for  me  when  I  told  him  that  she  had  a 
bursting  pelvic  cyst.  Mr.  Alban  Doran  has  examined  the  prepa- 
ration, and  confirms  my  opinion  that  the  cyst  is  the  right  Fallo- 
pian tube.  Doubtless  many  a  mysterious  case  of  peritonitis 
arises  from  some  such  cause  as  this. 

Thus  it  will  be  seen  that  recent  advances  in  pelvic  surgery, 
by  which  we  are  enabled  to  deal  with  a  great  number  of  cases 
which  formerly  were  left  to  unrelieved  suffering,  and  often  to 
inevitable  deatli.  have  made  it  clear  that  there  are  very  many 
cases  in  which  the  tubes,  having  become  occluded  by  acute  or 
chronic  inflammation,  are  occupied  by  purulent  fluid — a  condi- 
tion which  can  be  remedied  by  surgical  o])eration  alone. 

In  its  acute  stage  inflammation  of  the  tubes  is  a  most  formi- 
dable disease,  and  so  rajjidly  ends  in  general  peritonitis  that  we 
can  hardly  recognize  the  necessity  for  interfering  before  it  is  too 
late  to  do  anything.     I  have  seen  several  fatal  cases  of  peritoni- 


EKKOKS    OF    DEVKLOl'MHNT    OF    OVAlilFS    AND    OVIDUCTS.       GO 

tis  which  undoubtedly  had  their  origin  from  inflammation  of 
the  Fallopian  tabes,  and  which  ought  to  have  been  treated  by 
iibdominal  section.  Indeed,  I  do  not  think  I  shall  again  will- 
ingly allow  a  case  of  peritonitis  to  die  without  an  effort  to  save 
her  by  an  operation.  I  am  fully  persuaded  that  we  might  save 
many  such  cases  by  boldly  opening  the  abdomen  and  cleansing 
its  cavit}^  In  three  cases  of  chronic  peritonitis  I  have  done  this, 
and  cured  the  patients  completely. 

Pyo-salpinx  is,  however,  a  more  chronic  condition,  some  of 
the  cases  upon  which  I  have  operated  having  lasted  over  several 
years.  Probably  they  all  arise  in  some  acute  inflammation 
which  occludes  both  openings  of  the  tubes,  and  converts  one  or 
both — generally  both — into  chronic  abscesses  :  yet  in  the  last 
€ase  I  have  narrated  there  was  in  the  history  no  incident  of  an 
acute  kind.  Dr.  S.  Wilks  has  met  with  two  cases  where  pyo- 
salpinx  caused  general  pysemia,  one  case  proving  fatal  from  an 
abscess  in  the  liver,  the  other  from  an  abscess  in  the  brain. 

Besides  pus,  we  occasionally  find  that  an  occluded  Fallopian 
tube  may  contain  bloody  fluid  (hcemato-salpinx)  of  menstrual 
origin.  It  has  been  completely  established,  especially  by  the  ob- 
servations of  Bernutz  and  Goupil,  that  the  tubes  generally  share 
in  the  secretion  of  the  menstrual  fluid,  and  when  the  clamp 
used  to  be  employed  in  ovariotomy,  we  constantly  saw  menstrual 
weeping  from  the  stump.  It  is  not,  therefore,  surprising  that 
■occasionally  we  should  meet  with  a  case  of  haemato-salpinx. 
Dr.  Alfred  Medows  records  the  post-mortem  examination  of  one 
in  the  eighth  volume  of  the  ''Transactions  of  the  London  Obstet- 
rical Society,"  in  which  "  it  was  found  that  both  Fallopian  tubes 
were  enlarged,  not  regularly  and  uniformly,  but  so  as  to  form  a 
kind  of  cyst.  On  the  right  side  there  were  two  such  enlarge- 
ments ;  on  the  other,  one.  There  was  no  evidence  of  any  com- 
munication between  these  dilatations  and  the  fimbriated  open- 
ing. On  the  left  side  there  was  not  even  an  opening  into  the 
uterus,  the  ostium  uterinum  being  comj)letely  occluded.  They 
were  all  filled  with  a  dark,  thick,  grumous  fluid,  of  a  prune-juice 
•color.  It  is  evident  that,  in  this  case,  we  have  an  example  of 
what  Bernutz  and  Goupil  contend  for — menstrual  retention 
within  the  Fallopian  tube.  The  one  fact  which  is  clearly  re- 
vealed is,  that  the  Fallopian  tubes  do,  as  well  as  the  uterus,  take 
part  in  the  menstrual  secretion  :  and  hence,  when  any  obstruc- 
tion occurs  to  the  passage  of  that  secretion  into  the  uterine 
cavity,  and  so  externally,  we  get  the  resulting  symptoms  of 
menstrual  retention." 

The  following  case  has  occurred  in  my  practice,  and  I  have 


70  DISEASES    OF   THE   OVARIES. 

fortunately  been  able  to  operate  on  it  successfully.     The  patient 
remains  now  (1881)  in  perfect  health  : 

Miss  M ,  aged  thirty-eight,  was  sent  to  me  in  the  begin- 
ning of  1877,  by  my  friend  Mr.  Alfred  Freer,  of  Stourbridge.  In 
November,  1876,  she  had  an  ill-defined  illness,  during  which  she 
had  obscure  pelvic  pains,  accompanied  by  fever.  Previously  to 
this  illness  she  had  been  in  good  health,  and  had  menstruated 
regularly.  After  it,  she  had  severe  pain  during  the  whole  pe- 
riod of  menstruation,  and  she  gradually  increased  in  size  until 
Mr.  Freer  discovered  a  pelvic  tumor  in  February  last.  I  found 
the  tumor  to  be  pear-shaped,  quite  movable,  attached  to  the 
uterus  at  the  left  cornu,  evidently  unilocular,  and  about  the  size 
of  an  infant's  head.  I  diagnosed  it  as  a  cyst  of  the  parovarium, 
and  advised  that  it  should  be  tapped  after  it  had  increased  in 
size  sufficiently  to  warrant  interference.  She  returned  to  me  in 
May,  with  the  tumor  increased  so  as  to  be  felt  above  the  umbili- 
cus. I  advised  her  to  come  again  in  a  month.  She  came,  how- 
ever, before  the  expiration  of  that  period,  on  account  of  a  sudden 
accession  of  serious  symptoms;  and  when  I  saw  her,  on  June  20th. 
there  could  be  no  doubt  she  was  suffering  from  peritonitis.  Her 
pulse  was  130;  the  temperature  was  38.4°  C.  (101.12°  Fahr.),  and 
rose  to  39.6°  C.  (103.28°  Fahr.)  in  the  evening;  and  there  was 
excessive  pain  all  over  the  abdomen,  with  considerable  flatulent 
distention.  I  administered  opium  freely,  and  applied  counter- 
irritation  over  the  epigastrium. 

On  the  morning  of  the  21st  she  was  easier,  but  the  tempera- 
ture and  pulse  had  not  fallen.  I  therefore  had  her  placed  under 
the  influence  of  ether  by  Dr.  A.  H.  Carter,  and  proceeded  to  open 
the  abdomen,  assisted  by  Mr.  Priestley  Smith.  The  tissues  of  the 
abdominal  walls  were  extremely  vascular,  and  it  was  necessary 
to  use  a  large  number  of  ligatures  to  arrest  the  bleeding.  The 
peritoneum  was  found  to  be  intimately  adherent  to  the  tumor, 
and,  as  soon  as  the  latter  had  been  laid  bare  for  a  short  distance, 
it  became  evident  that  it  was  not  an  ovarian  tumor,  but  pre- 
sented the  red,  muscular  appearance  of  the  uterus.  Passing  the 
foreflnger  of  my  left  hand  down  as  deeply  as  I  could  in  front  of 
the  tumor,  with  that  of  my  right  hand  in  the  vagina,  I  made  out 
distinctly  enouf^'h  that  my  original  conception  of  the  relations  of 
the  tumor  to  the  uterus  were  perfectly  correct.  Under  the  sus- 
picion that  it  might  be  a  tubal  pregnancy,  I  did  not  separate  the 
tumor  further,  as  I  had  not  opened  tlie  peritoneal  cavity,  but  cau- 
tiously opened  the  cyst  in  the  middle  line  by  means  of  a  knife. 
As  soon  as  I  had  reached  its  inner  coat,  I  passed  my  small  trocar 
in,  and  evacuated  about  six  quarts  of  thick,  dark  brown  fluid. 


ERliOnS    OF   DEVELOPMENT   OF    OVAIIIES    AND    OVIDUCTS.       71 

having  the  peculiar  smell  of  menstrual  fluid.  After  the  cyst 
was  emptied,  I  passed  my  finger  through  the  hole  made  by  the 
trocar,  and,  to  my  amazement,  I  found  that  the  cyst  had  con- 
tracted ;  moreover,  as  I  kept  my  finger  in  tlie  cavity,  I  distinctly 
felt  it  contracting  round  and  grasping  my  finger.  Passing  the 
forefinger  of  my  other  hand  into  the  vagina,  I  made  out  that  what 
I  had  opened  was,  beyond  doubt,  the  left  Fallopian  tube,  and  that 
I  must  have  opened  it  close  to  its  fimbriated  extremity.  I  could 
find  no  canal  leading  into  the  uterus,  and  did  not  deem  it  advis- 
able to  make  one.  I  washed  out  the  cavity  freely  with  weak 
carbolic  lotion,  by  reversing  the  syphon  action  of  my  trocar. 
The  wound  was  closed  by  four  deep  sutures,  one  of  which  was 
so  arranged  as  to  fasten  in  a  loop  of  wire  drainage-tube  ;  but  be- 
fore this  was  done  I  acted  on  a  hint  from  Mr.  Priestley  Smith, 
and  snipped  off  a  piece  of  the  cyst- wall  for  microscopic  exam- 
ination. This  fragment  proved  to  be  composed  of  an  abundance 
of  unstriped  muscular  fibre,  conclusively  supporting  the  view 
that  this  singular  tumor  was  a  distended  Fallopian  tube.  After 
the  operation  I  treated  her  exactly  as  a  case  of  ovariotomy. 
Her  temperature  fell  slowly.  The  wound  suppurated  freely,  and 
shreds  of  what  was  undoubtedly  mucous  membrane  came  away 
with  the  discharge  in  large  quantity.  The  drainage-tube  was 
removed  on  the  twenty-first  day,  and  its  track  continued  to 
discharge  until  the  beginning  of  August.  It  then  healed,  and 
she  is  now  (October  18,  1881)  in  perfect  health.  She  has  never 
menstruated  since  the  operation. 

From  the  fortunate  issue  of  this  case  much  is  left  to  specula- 
tion, but  of  the  nature  of  the  tumor  there  is  no  doubt.  As  to  its 
origin,  it  seems  to  me  that  it  may  be  accounted  for  by  the  sup- 
position that  the  illness  from  which  all  her  symptoms  dated  was 
a  localized  salpingitis,  which  resulted  in  the  closure  of  the  two 
ends  of  the  tube.  The  peritonitis,  which  she  undoubtedly  had 
when  I  operated  on  her,  I  suggest  was  due  to  a  threatening  rup- 
ture of  the  tube,  and  possibly  a  slight  escape  of  its  contents.  If 
this  be  so,  it  is  evident  that  it  was  only  the  accident  of  my  de- 
termination to  act  promptly  which  saved  the  patient's  life. 

Arthur  Farre  quotes  a  case  of  this  kind,  in  which  the  disten- 
tion by  the  menstrual  fluid  advanced  to  rupture,  followed,  of 
course,  by  death.  I  think  my  case  was  on  the  verge  of  a  similar 
fate. 

Dr.  Mathews  Duncan  has  for  a  long  time  insisted  that  occa- 
sionally the  Fallopian  tube  might  be  patent  so  far  as  to  admit 
the  passage  of  the  sound  through  it.  I  am  bound  to  say  that  1 
have  never  seen  any  evidence,  from  my  own  experience,  that 


72  DISEASES    OF   THE    OVARIES. 

such  a  condition  has  occurred,  though  I  have  admitted  its  possi- 
biUty.  The  cases  in  which  it  is  stated  to  have  occurred  I  have 
always  regarded  as  instances  of  the  passage  of  the  sound  through 
the  fundus,  an  incident  to  which  Simpson  drew  attention,  very 
many  years  ago,  as  of  not  infrequent  occurrence.  In  the  Lancet 
of  1872,  I  have  reported  authenticated  instances  of  this  curious 
fact.  In  the  British  Medical  Journal  of  March  12,  1881,  Dr. 
Duncan  has  published  a  paper  in  which  he  gives  some  very  curi- 
ous information  on  the  subject  of  "  Open  Fallopian  Tube,"  and 
though  I  am  still  somewhat  sceptical,  I  give  the  following  ex- 
tract from  his  paper,  in  order  to  draw  attention  to  the  subject. 
That  it  is  not  impossible  is  certain  from  the  fact  that  in  cases  of 
parovarian  cysts,  where  the  tube  is  often  wound  around  the  base 
of  the  tumor,  and  greatly  increased  in  length  and  thickness,  it 
is  sometimes  possible,  with  care,  to  pass  a  No.  4  or  5  male  cathe- 
ter through  the  tube. 

"Investigating  the  pelvic  conditions  of  a  case  destined  by  a 
colleague  for  ovariotomy,  I  found  the  uterine  probe  pass  to  the 
right  side  of  the  pelvis,  and  far  beyond  the  limits  of  the  uterine 
body,  which  was  easily  and  certainly  felt.  When  the  woman 
was  on  the  operating-table,  I  failed  to  pass  the  probe  again 
through  the  tube,  probably  from  the  unfavorable  circumstances 
under  which  the  attempt  was  made.  A  few  days  subsequently, 
in  the  post-mortem  examination,  the  right  tube  was  observed 
lying  in  the  route  which  the  probe  had  taken,  and  its  uterine 
extremit}^  was  patent — not  to  the  extent  of  being  wide  enough 
to  transmit  a  uterine  sound,  with  its  large,  bulbous  point,  but  to 
transmit  a  common  small  surgical  probe. 

"  Interesting  evidence  of  the  patency  of  the  tubes  is  found  in 
the  intra-uterine  clots  discharged  in  some  cases  of  metrorrhagia. 
These,  coming  away  as  models  of  the  uterine  cavity,  bear,  at 
their  upper  angles,  long  clots  drawn  out  of  the  tubes,  and  found 
hanging  from  the  main  intra-uterine  clot.  Appendages  of  the 
same  appearance  and  origin  may  be  found  attached  to  the  de- 
cidua  in  cases  of  abortion  (see  the  author's  '  Researches  in  Ob- 
stetrics,' p.  29G);  but  these  are  decidual  in  structure,  and  have 
some  strength,  and  are  not  extracted  from  the  tube,  but  are  part 
of  the  tube.  They  do  not  indicate  patency;  but  the  extraction 
of  a  long  clot,  so  delicate  and  perishable  as  it  is.  attached  only 
by  the  feeble  cohesion  of  coagulation  to  the  main  intra-uterine 
clot,  indicates  a  decided  patency  of  the  canal  from  which  it 
passed.  In  Pirie's  case  (Ob.stetrical  Journal,  January,  is.so,  p.  5), 
•  the  upper  part  of  the  clot  was  firm,  even  somewliat  tough,  and 
the  tubal  cords  were  nearly  four  inches  long.'  In  the  case  of 
O.  Knkitansky  {ibid.,  March,  1880,  p.  13.')),  the  body  of  the  uterus 


EKKOIIS    OF    DEVELOPMENT    OF    OVAilIES    AXD    OVIDUCTS.       73 

contained  *  a  three-cornered  coagulum,  ending  above,  on  both 
sides,  in  a  short,  thin  thread  running  to  the  tubes.'  Whitehead 
{ibid.,  March,  1880,  p.  137)  says  that,  in  his  case,  'small  fibrous 
prolongations  from  the  clot  corresponded  to  the  Fallopian  tubes.' 

•'  Of  the  possible  evil  results  of  persistent  patency  of  a  Fallo- 
pian tube,  the  following  is  an  example,  related  to  me  by  Mr, 
Hewer,  as  having  occurred  in  the  practice  of  his  partner,  Mr, 
Calthrop.  A  widow,  aged  forty-eight,  had  a  polypus  of  the 
cervix  snipped  off  by  scissors.  On  the  fifth  day  after  the  opera- 
tion her  sister  gave  her,  gently,  a  vaginal  injection  of  warm 
water  with  Condy's  fluid.  While  receiving  the  injection  the 
patient  cried  out,  '  You  have  killed  me,'  and  was  seized  with 
sudden  pain  in  the  right  side  of  the  abdomen.  She  lived  for 
three  days,  in  great  pain  till  within  a  few  hours  of  death.  On 
post-mortem  examination  there  was  found  general  peritonitis, 
with  flaky  lymph  on  the  intestines.  The  right  Fallopian  tube 
was  seen  to  be  much  larger  than  the  left — twice  as  broad  :  it  was 
freely  patulous.  The  section  of  the  pedicle  of  the  jiolypus  was 
healthy.  There  were  two  other  polypi  in  the  cervix.  Here,  as 
Mr.  Hewer  says,  it  was  plain  that  the  injected  fluid  jjassed  into 
the  peritoneal  cavity  through  a  canalized  tube,  and  caused  peri- 
tonitis and  death.  Of  this  accident  many  cases  are  now  on 
record,  the  injections  being  either  vaginal,  as  in  Hewer's  case, 
or  intra-uterine. 

"  By  the  same  route  I  have  long  held  that  blood  frequently 
passes  from  the  uterine  cavity  into  the  peritoneal  cavity,  and 
gives  rise  to  haematocele.  Indeed,  I  incline  to  the  opinion  that 
this  diversion  of  blood,  whether  menstrual,  menorrhagic,  or 
metrorrhagic,  is  the  most  frequent  cause  of  this  not  uncommon 
disease.  Of  course  it  is  necessary  to  suppose,  what  has  been 
well  accounted  for,  that  the  morbid  course  of  the  blood  is  me- 
chanically easier  than  the  natural  or  ordinary  one  through  the 
cervix  uteri  into  the  vagina  ;  and  there  can  further  be  no  doubt 
that,  ordinarily,  even  when  a  tube  is  patent,  the  mechanically 
easier  progress  of  the  blood  is  through  the  cervix  into  the  vagina. 
Were  it  not  so,  hsematocele  would  be  much  more  frequent  than 
it  is.  I  have  often  known  a  woman  lose  blood  from  her  uterus 
per  vaginam  while  a  tube  was  freely  patent. 

'•  Besides  the  passage  of  blood,  there  is  the  almost  certain, 
but  very  rare,  passage  of  a  lumbricus  through  a  patent  tube 
(Winckel:  '  Die  Pathologie  der  weiblichen  Sexual-Organe,'  S.321). 
This  kind  of  passage  is  effected  by  the  movements  of  the  animal. 

"  Further,  openness  of  a  tube  is  a  necessary  condition  for  the 
accomplishment  of  the  wandering  of  the  ovum  in  certain  cases 
of  extra-uterine  pregnancy. 


7-i  DISEASES   OF   THE   OVARIES. 

"  In  conclusion,  it  is  necessary  to  remember  that,  besides 
natural  and  morbid  conditions  of  patency,  there  may  be  unnatu- 
ral absence  of  temporary  patency,  or  of  occasional  dilatation  of 
the  tubes ;  for  it  is  probable  that  they  dilate  during  sexual  ex- 
citement, and  permit  the  passage  of  the  semen.  Indeed,  it  is 
scarcely  conceivable  that  semen  can  permeate  the  tubes  while 
they  are  in  their  usual  closed  state.  This  absence  of  dilatability 
of  the  tubes,  or  their  rigidity,  may  thus  be  a  cause  of  barren- 
ness. 

"  The  proposition  of  Tyler  Smith  to  catheterize  the  tubes,  and 
thus  cure  sterility,  was  brought  forward  under  the  influence  of 
different  theoretical  views  from  those  expressed  in  this  paper. 
It  has,  as  yet,  led  to  no  more  practical  result  than  the  proposal 
of  Froriep  to  close  them  by  cauterization,  in  order  to  produce 
sterility." 

Of  course  I  need  hardly  say  that  I  regard  such  views  as  Dr. 
Duncan  liere  expresses  concerning  the  passage  of  semen  up  the 
tube  as  wholly  contrary  to  fact,  and  quite  irreconcilable  with 
what  I  have  already  said  concerning  the  physiology  of  the  tubes. 

Simpson  relates  a  case  of  simple  hypertrophy  of  the  muscu- 
lar coat  of  the  walls  of  the  tubes.  Various  authors  also  men- 
tion tumors  as  having  been  found  in  their  substance,  but  the 
majority  of  these  cases  are  not  described  with  sufficient  mi- 
nuteness of  anatomical  detail  to  enable  us  to  accept  them  im- 
plicitly. Myomata  of  small  size,  as  we  might  expect  from  the 
structure  of  the  tubes,  have  been  repeatedly  found,  and  about 
their  occurrence  there  can  be  no  doubt.  Cancer  and  tubercle 
extend  into  the  tubes  from  the  uterus  ;  but  we  may  dismiss  all 
these  conditions  by  saying  that  their  diagnosis  is  impossible, 
and  that  it  would  be  of  little  importance  if  it  could  be  made. 

Occasionally  calcareous  concretions  have  been  found  in  the 
tubes,  possibly  the  result  of  old,  chronic  abscesses.  The  clinical 
history  of  such  cases  is  never  given.  The  organ  of  Rosenmiiller, 
a  small  cyst  which  remains  from  the  ducts  of  the  Wolffian  body, 
is  a  curious  feature  of  the  outer  part  of  the  tube.  I  believe  that 
sometimes  it  undergoes  cystic  enlargement,  and  should  be  treat- 
ed as  an  ovarian  tumor.  In  one  of  my  recent  ovariotomies  I 
found  it  to  be  about  four  or  five  times  its  usual  size,  and  I  re- 
moved it. 

One  of  the  most  important  abnormalities  of  the  Fallopian 
tube  is  that  in  which  the  ovum  comes  in  contact  witli  spermato- 
zoa during  its  passage  through  the  canal,  becomes  adherent  to 
its  walls,  and  develops  into  a  Fallopian  pregnancy.  This  acci- 
dent occurs  probably  when  the  ciliary  action  of  the  mucous  lin- 
ing is  destroyed  by  some  desquamation  or  other  accident,  for  I 


EKKOIJS   OF   DEVELOPMENT   OB^   OVARIES   AND   OVIDUCTS.      75 

have  already  stated  that  I  do  not  believe  that  impregnation  takes 
place  in  the  tubes  save  under  exceptional  circumstances,  and 
when  it  does  occur  the  probabilities  are  great  that  the  fertilized 
ovum  will  there  contract  the  adhesions  which  it  ought  to  have 
in  the  uterus.  When  this  misfortune  does  occur,  the  tube  ex- 
pands to  a  certain  limit,  that  limit  being  reached  between  the 
second  and  third  months  of  pregnancy,  at  which  time  rupture 
usually  takes  place.  In  the  vast  majority  of  cases  that  rupture 
is  fatal,  and  I  am  sure  that  there  is  no  experienced  gynecologist 
who  has  not  seen  at  least  scleral  instances  of  it.  I  have  known 
at  least  twenty  post-mortem  examinations  of  women  who  have 
died  from  ruptured  tubes.  In  not  a  single  instance  which  I 
have  seen,  nor  in  any  of  which  I  have  found  record,  has  the 
pregnancy  been  anywhere  but  in  the  tube.  The  cause  of  death 
in  these  cases  of  tubal  rupture  is  invariably  hemorrhage,  and 
the  source  of  hemorrhage  is  the  enlarged  maternal  vessels  ao 
the  site  of  the  placenta.  Unfortunately,  it  is  just  here  that  the 
rupture  nearly  always  occurs,  because  the  tissues  are  thinner, 
more  vascular,  and  more  easily  torn  than  elsewhere.  These 
facts  I  was  able  abundantly  to  prove  in  a  case  which  I  at- 
tended with  my  friend  Mr.  Hall- Wright,  in  which  I  removed 
the  parts  en  masse,  and  succeeded  in  injecting  them  perfectly. 
Occasionally  this  rupture  takes  place  without  hemorrhage,  or  at 
least  without  fatal  hemorrhage,  and  the  patients  survive  the 
accident.  In  what  percentage  this  fortunate  issue  occurs  Ave  do 
not  yet  know,  but  it  is  probably  not  large.  By  the  rupture  the 
ovum  is  extruded  into  the  peritoneal  cavity  or  between  the 
layers  of  the  broad  ligament,  the  latter  being  an  exceptional  and 
a  very  favorable  occurrence,  because  the  patient  is  not  likely  to 
die  of  the  hemorrhage. 

It  was  after  the  dissection  of  a  case  of  this  kind,  described  by 
Dezeimeris  as  "  subperitoneo-pelvic  "  (his  second  variety  "sous- 
peritoneo-pelvienne"),  that  I  was  led  to  reconsider  the  whole 
question  of  the  pathology  of  this  important  subject.  Up  to  that 
time  we  had  accepted  the  involved  classification  of  the  author 
I  have  just  quoted,  who  made  out  ten  different  varieties.  Grow- 
ing experience  and  the  consideration  of  a  large  number  of  re- 
corded cases  have,  however,  induced  me  fully  to  adopt  the  view 
of  the  origin  of  all  cases  of  extra-uterine  pregnancy  which  I  first 
laid  before  the  Obstetrical  Society  of  London  in  1873.  Of  this 
view  the  late  Dr.  John  S.  Parry,  in  his  exhaustive  treatise  on 
the  question,  says  :  "  In  opposition  to  this  minute  anatomico- 
pathological  classification  of  Dezeimeris,  we  have  the  simple  one 
of  Mr.  Lawson  Tait,  who  asserts  that  there  are  only  two  forms  of 
misplaced  conception.    In  one  the  oviduct  bursts,  the  peritoneum 


76  DISK  AS  K8    OF   THE   OVARIES. 

remaining  uninjured,  after  which  the  ovum  escapes  into  the 
broad  ligament,  between  the  folds  of  which  its  development 
-continues.  In  the  other  variety  the  peritoneum  is  lacerated,  as 
well  as  the  walls  of  the  tube,  and  the  ovum  finds  its  way  into 
the  cavity  of  the  abdomen.  The  first  is  the  subperitoneo-pelvic 
pregnancy  of  the  French  authors,  and  the  latter  is  the  secondary 
abdominal  pregnancy  of  Boehmer. 

••Prof.  T.  G.  Thomas,  of  New  York,  has  recently  promulga- 
ted opinions  in  support  of  those  of  Mr.  Tait.  He  writes  {New 
York  Medical  Journal,  June,  1875):  *I  feel  inclined  to  believe 
that,  in  the  commencement  of  its  development,  the  impregnated 
ovum  never  attaches  itself  to  or  draws  its  nourishment  from 
any  other  parts  than  those  lined  by  the  mucous  membrane  of  the 
uterus  or  tubes.  Knowing,  as  we  do,  the  delicate  and  subtile 
connection  which  the  chorion  establishes  with  the  maternal  tis- 
sues, it  is  certainly  difficult  to  believe  that  an  impregnated 
ovum,  falling  free  into  the  peritoneal  cavity,  or  detained  witliin 
the  Graafian  vesicle,  can,  with  parts  so  unlike  the  lining  of  the 
uterus,  establish  relations  almost  identical  with  those  which  are 
normal.'  " 

These  opinions  of  Prof.  Thomas  are  quite  in  accord  with  my 
own,  and  it  has  further  always  seemed  to  me  that  the  idea  that 
an  ovum  could  be  impregnated  in  the  ovary  and  then  pass,  not 
through  the  Fallopian  tube,  but  into  the  peritoneal  cavity,  and 
then  out  through  the  membrane  into  the  tissue  of  the  broad 
ligament,  was  alike  improbable  and  far-fetched.  It  was  much 
more  likely,  and  the  dissection  in  my  case  made  me  certain,  that 
this  exceptional  form  arises  merely  from  the  rupture  of  the  tube 
in  an  ordinary  tubal  pregnancy,  the  wall  giving  way  at  the 
lower  part,  and  allowing  the  ovum  to  extrude  into  the  connective 
tissue  between  the  two  layers  of  the  broad  ligament.  This  con- 
viction led  me  still  farther.  It  made  me  examine  other  cases  of 
which  I  had  the  preparations,  or  which  I  met  with  in  practice 
sul)sequently,  with  great  care,  and  I  became  convinced  that  in 
every  instance  the  pregnancy  was  tubal  originally,  and  that 
tlie  acquired  relations  of  the  ovum  depended  entirely  on  the 
accidents  of  the  direction  and  extent  of  the  rupture  of  its  en- 
velopes. 

(M  course  some  sub-varieties  may  be  made  out  of  the  position 
of  the  original  attachment  of  the  ovum  in  the  tube,  but  these  can 
be  referred  to  only  in  specimens  of  the  displacement  in  an  early 
stage.  In  the  later  stages  of  the  pregnancy  all  sucli  distinctions 
must  certainly  be  lost,  unless  it  be  that  which  has  been  termed 
iuterstitial. 

The  varieties  which  mav  thus  be  made  are  three  in  number  : 


ERKoii.s  OF  devjolopmp:nt  of  ovaries  and  oviducts.     77 

(a),  tiibo-ovarian,  when  the  ovum  has  been  fertilized  in  the  in- 
funclibulum  before  the  separation  has  occurred  between  that 
structure  and  the  surface  of  the  ovary  ;  (b),  tubal ;  and  (c),  inter- 
stitial, where  the  attachment  has  been  formed  to  that  part  of  the 
tube  lying  in  the  uterine  wall. 

There  can  be  no  doubt  that  the  former  variety  has  been  accu- 
rately described  and  fully  established,  but  of  the  so-called  ova- 
rian pregnancy  I  shall  have  something  to  say  in  the  chapter  on 
ovarian  tumors. 

The  interstitial  variety  is  very  likely  to  be  far  more  common 
than  w^e  have  hitherto  suspected,  for  there  is  little  doubt  that  it 
can  and  does  end  by  natural  labor  at  the  full  term.  (See  John 
S.  Parry's  scholarly  and  complete  treatise.) 

This  distinction  of  varieties  has,  however,  but  little  practical 
importance,  save,  perhaps,  in  being  associated  with  a  like  distri- 
bution of  the  frequency  of  disastrous  rupture  of  the  structures, 
and  death  by  hemorrhage.  One  would  expect  that  the  tubo- 
ovarian  variety  would  be  most  likely  to  have  this  occurrence, 
and  that  the  interstitial  variety  would  be  the  least  likely  ;  but 
there  are  no  established  data  upon  which  to  make  any  state- 
ment. 

It  is  at  any  rate  certain  that  when  an  impregnated  ovum  at- 
taches itself  to  any  part  of  the  tube  outside  the  uterus,  rupture 
of  some  of  the  structures  will  take  place  before  the  fourth  month, 
probably  very  much  earlier.  If  the  extrusion  takes  place  into 
the  abdominal  cavity,  the  membranes  may  either  remain  entire 
and  be  developed  with  the  foetus,  or  they  may  rupture,  and  the 
foetus  will  then  float  loose  in  the  cavity  of  the  abdomen.  Mean- 
while the  placenta  retains  its  old  attachment  to  the  inner  surface 
of  the  tube,  which  becomes  everted,  and  it  likewise  acquires  new 
attachments,  as  it  grows,  to  the  front  of  the  rectum,  ovaries, 
various  parts  of  the  peritoneal  surface,  and  even  to  the  small 
intestines.  Wherever  it  may  attach  itself,  it  displays  a  marvel- 
lous power  of  sending  villi  into  the  structures,  and'inducing  an 
enormous  enlargement  of  the  vessels  in  the  neighborhood. 
These  enlarged  vessels,  as  I  have  seen  on  injection,  appear  more 
like  sinuses  than  ordinary  vessels.  Their  walls  are  very  thin 
and  have  no  distinct  muscular  layer,  a  fact  wdiich  at  once  ex- 
plains the  disastrous  results  which  have  always  followed  at- 
tempts to  remove  the  placenta  in  operations  for  extra-uterine 
gestation,  the  hemorrhage  being  quite  uncontrollable.  It  also 
explains  the  profuse  hemorrhage  which  follows  a  compara- 
tively insignificant  rupture  of  an  organ  not  usually  very  vas- 
cular. 

It  will  be  seen,  therefore,  that  I  maintain  that  everv  case  of 


DISEASES    OF   THE    OVARIES. 


extra-uterine  pregnancy  is  tubal  in  its  origin,  and  that  it  may 
become  intra-peritoneal  or  extra-peritoneal,  just  as  the  tube  hap- 
pens to  burst.  The  intra-peritoneal  termination  is  beyond  all 
question  the  more  common  and  the  more  fatal ;  while  the  extra- 
peritoneal development  of  the  ovum  is  much  rarer,  less  fatal, 
and,  what  is  of  more  consequence,  far  more  amenable  to  treat- 
ment. 

The  diagnosis  of  extra-uterine  gestation  in  its  early  stage  is 

Fatal  Case  of  Fallopian  Pregnancy  at  Eighth  Week  (after  Duguet). 


.^> 


Fig.  22 — A,  Utenis  laid  open  on  the  anterior  surface :  /?,  part  of  the  decidua  still  adhcrmt  to  the  ri^ht 
uterine  cornu :  C,  decidua,  nearly  entire,  expelled  before  death ;  D,  right  tube  and  ovary,  normal ;  E.  E, 
inar<rina  of  artificial  o))ening  in  the  left  tube  ;  P,  umbilical  cord  ;  G,  ])lacenta;  IT,  ])avilion  of  the  left  tube  ; 
/.  vascular  plexus,  ramifying  over  the  tubal  covering  of  cyst,  from  which  the  hemorrhage  occurs  on  its  rup- 
ture :  J,  vagina. 


./ 


Fio.  23.— /I.  View  of  the  posterior  surface  of  the  uterus :  S.  fimbria;  of  left  tube ;  C,  C,  C,  rent*  in 
tubal  coverintf  of  cyst,  corresponding  to  site  of  placenta,  from  which  the  foetus  escaped  and  hemorrha};e 
came ;  Z>,  ovary  attached  to  lower  surface  of  cyst,  and  increased  in  size ;  E,  right  tube. 


surrounded  with  difficulties,  and  we  are  seldom  called  upon  to 
consider  it  until  nearly  all  hope  of  successful  interference  is  over. 
I  refer,  of  course,  to  the  class  of  cases  which  we  see  at  the  time 
of  the  tubal  rupture,  and  which  are  generally  included  under 
the  head  of  intra-i)eritoneal  ha^matocele. 


ERRORS    OF   DEVELOPMENT   OE   OVARIES   AND   OVIDUCTS.      79 

I  have  very  little  doubt,  however,  that  many  of  these  cases 
would  be  saved  by  prompt  action.  The  difficulty  is,  of  course, 
in  the  diagnosis,  some  certainty  of  which  is  requisite  before  an 
abdominal  section  can  be  performed.  I  have  twice  been  on  the 
point  of  performing  abdominal  section  on  account  of  suspected 
rupture  of  a  Fallopian  tube,  and  have  been  prevented  by  scruples 
as  to  the  correctness  of  the  diagnosis.  In  both  cases  post-mortem 
abdominal  section  showed  that  the  suspicion  was  correct,  and  I 
believe  both  of  these  patients  might  have  been  saved.  A  hesita- 
tion in  opening  the  abdominal  cavity  was  natural  enough  when 
we  were  overburdened  with  the  superstition  that  it  was  a  very 
serious  step;  but  now  that  we  know  it  can  be  done  with  perfect 
safety,  I  would  not  hesitate  to  explore  in  a  case  where  I  sus- 
pected a  Fallopian  rupture.  If  my  suspicion  were  verified,  I 
would  apply  a  ligature  to  the  rupture  after  I  had  completely 
emptied  the  sac,  or  I  would  completely  remove  the  broad  liga- 
ment, or  perhaps  stitch  it  to  the  abdominal  wound,  and  drain  it, 
as  I  have  done  with  pelvic  abscesses,  dropsy  of  the  gall-bladder, 
hydrated  cysts  of  the  liver  and  kidney,  etc.  In  this  way  I  think 
some  of  these  terrible  cases  might  be  saved. 

I  have  chiefly  to  speak  of  the  cases  which  survive  this  first 
and  greatest  risk  of  death  from  hemorrhage.  Usually  we  do  not 
see  them  until  some  months  after  the  time  of  their  expected  con- 
finement, and  after  the  child  has  died.  In  very  rare  instances 
our  assistance  is  asked  before  this  period,  and  in  these  the  ut- 
most care  must  be  exercised  before  the  diagnosis  is  acted  upon. 
Of  course,  if  the  child  is  found  loose  in  the  abdomen  and  moving 
about,  the  diagnosis  is  as  simple  as  that  of  a  fractured  leg,  and 
the  mere  division  of  the  abdominal  walls  will  end  the  displace- 
ment. Only  one  such  fortunate  case  is  as  yet,  however,  on  record 
—that  which  recently  has  been  published  by  Mr.  Jessop,  of 
Leeds. 

But  supposing  that  the  child  is  still  enveloped  in  a  sac  of  some 
kind,  and  alive,  how  can  we  determine  that  it  is  not  in  the  uterus  ? 
I  confess  that,  short  of  introducing  the  sound  or  the  finger  into 
the  cavity,  I  know  of  no  means  of  certain  diagnosis,  and  that  pro- 
ceeding can  be  justified  only  by  urgent  symptoms.  Since  I  wrote 
originally  upon  this  subject,  I  have  repeatedly  been  called  to 
cases  where,  for  some  reason  or  other,  extra-uterine  pregnancy 
with  a  living  child  was  suspected,  but  in  not  a  single  instance 
did  the  result  justify  the  suspicion,  and  my  invariable  advice  to 
wait  for  symptoms  always  resulted  in  our  waiting  for  ordinary 
labor.  In  one  case  in  the  practice  of  Mr.  Langley  Browne,  of 
West  Bromwich,  we  found  a  very  thin  uterus  extremely  retro- 
verted.     In  the  others  the  conditions  were  those  of  extremely 


80  DISEASES    OF   THE    OVARIES. 

thin  walls,  with  some  kind  of  displacement,  as  latero-flexion  or 
retroflexion,  and  in  these  patience  always  solved  the  doubts.  If 
I  met  with  a  case  where  any  urgent  symptoms  existed,  I  would 
not  hesitate  to  use  the  sound  or  use  my  dilators  if  necessary  ; 
for  the  worst  that  could  happen,  in  the  event  of  mistake,  would 
be  a  premature  labor. 

This  condition  of  extreme  thinness  of  the  uterine  walls,  in  a 
pregnancy  perfectly  normal  in  every  other  respect,  is  a  point 
which  has  not  yet  received  any  notice,  so  far  as  I  know.  It  is, 
however,  of  sufficiently  common  occurrence  to  be  a  source  of 
difficulty  and  danger,  and  therefore  I  propose  to  say  here  what 
I  have  noticed  about  it,  in  the  hope  that  it  may  draw  the  atten- 
tion of  some  one  engaged  in  obstetric  practice  who  may  be  able 
to  investigate  it  more  fully.  I  can  now  recall  six  cases  in  which 
1  have  been  consulted  concerning  a  supposed  extra-uterine  preg- 
nancy, yet  in  which  there  was  only  an  extreme  thinness  of  the 
uterine  walls.  I  have  no  record  of  three  of  the  cases,  but  of  the 
others  I  have  more  accurate  data  than  mere  recollection.  The 
features  of  all,  however,  had  much  in  common,  and  the  known 
histories  of  three  quite  establish  this.  The  ordinary  symptoms 
of  pregnancy  were  present  in  all  of  them,  and  in  only  one  was 
there  any  doubt  as  to  its  existence.  The  question  generally  was. 
Is  the  child  in  the  abdominal  cavity?  and  sometimes  I  had  great 
difficulty  in  persuading  the  gentlemen  who  brought  the  patients 
to  me  that  the  position  of  the  child  was  normal.  Save  in  one 
case — that  seen  by  me  with  Dr.  Whitwell,  at  Shrewsbury— there 
was  a  marked  absence  of  the  liquor  amnii,  so  that  the  move- 
ments of  the  child  could  be  seen  and  felt  in  a  most  striking  man- 
ner. In  the  pelvis  the  finger  comes  upon  the  presenting  part 
of  the  foetus,  as  if  it  lay  immediately  under  the  mucous  mem- 
brane ;  and  it  was  only  on  very  careful  investigation  that  the 
attenuated  cervix  uteri  could  be  made  out.  spread  over  the  body 
of  the  child. 

These  cases  were  all  under  the  seventh  month.  In  the  eighth 
and  ninth  months  the  walls  of  the  uterus  thickened,  the  quantity 
of  liquor  amnii  increased,  and  the  cases  terminated  in  perfectly 
natural  labors. 

These  facts  were  given  to  me  in  connection  with  Mr.  Langley 
Browne's  case,  also  with  a  case  which  was  watched  by  Dr.  Hill 
Norris,  and  attended  by  him  in  her  confinement.  In  Dr.  Whit- 
well's  case,  which  I  saw  with  him  last  August,  there  was  a  large, 
thin-walled  cyst,  through  which  tlio  child  could  be  felt  with  the 
most  astonishing  distinctness,  and  it  floated  about  as  if  it  were 
perfectly  free  in  the  abdomen.  He  writes  to  me  that  "the  pa- 
tient went  on  very  well,  that  some  time  before  the  expiry  of 


ERRORS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      81 

gestation  the  foetus  became  much  more  a  fixed  body,  which  un- 
doubtedly showed  an  increased  thickening-  of  the  walls  of  the 
uterus,  as  well  as  enlargement  of  the  foetus,  and  that  her  labor 
was  quick  and  without  any  subsequent  hemorrhage." 

The  other  conditions  with  which  extra-uterine  jjregnancy  may 
be  confused,  before  the  death  of  the  child,  are  (a)  displacement  of 
the  normally  pregnant  uterus  during  the  early  months  of  preg- 
nancy, complicated  with  fibro-myoma  or  cystic  disease  of  the 
uterus  ;  and,  more  rarely,  (b)  pregnancy  of  one-half  of  a  double 
uterus.  In  a  case  which  I  saw  with  the  late  Mr.  Ross,  of  Wake- 
field, I  diagnosed  either  extra-uterine  gestation  or  a  double 
uterus  with  pregnancy  of  one  side,  and  it  turned  out  to  be  the 
latter.  Frequently  we  have  considerable  lateral  displacements 
of  the  normally  pregnant  uterus,  especially  in  unmarried  women, 
sent  to  the  specialist  as  something  very  different  from  what  they 
really  are. 

But  it  is  in  cases  seen  after  the  death  of  the  child,  or  at  least 
when  the  time  of  the  expected  confinement  has  passed  so  long 
that  if  there  is  a  child  it  is  sure  to  be  dead,  that  our  most  serious 
difficulties  in  diagnosis  are  met  with. 

The  first  point  to  consider  is  the  history  given  by  the  patient 
of  her  supposed  pregnancy,  and  the  events  which  occurred  at 
and  after  the  time  of  her  expected  delivery.  It  is  somewhat 
remarkable,  and  I  think  it  is  in  favor  of  the  views  of  the  pathol- 
ogy of  tubal  pregnancy  which  I  have  advanced,  that  the  ma- 
jority of  the  instances  of  this  abnormality  occur  in  women  who 
have  not  borne  children  previously,  or  in  those  who  have  had  no 
children  for  many  years.  This  point  in  the  history  of  the  pa- 
tient is  therefore  always  noteworthy.  The  other  matters  requir- 
ing careful  consideration  are  the  sudden  arrest  of  the  menses, 
the  gradual  increase  in  size,  the  occurrence  of  symptoms  of  labor 
at  or  about  the  end  of  the  ninth  month,  and  the  subsequent  dim- 
inution in  size.  Of  all  those  points,  the  last  is  the  only  one 
having  the  importance  of  a  sign  ;  but  it  must  always  be  borne 
in  mind  that  no  history,  however  complete,  is  of  sufficient  v.^eigiit 
to  establish  a  diagnosis  unless  there  be  some  distinct  physical 
signs  in  support  of  it.  This  I  lay  down  as  a  rule  based  upon  a 
remarkable  experience,  which  I  published  in  detail  in  the 
"  Transactions  of  the  Obstetrical  Society  of  London  "  for  1874. 
In  this  case  I  had  diagnosed  double  ovarian  tumor,  but  was  com- 
pletely misled  by  a  subsequent  history  which  the  patient  volun- 
teered. This  was  to  the  effect  that  just  three  years  before  she 
had  believed  herself  pregnant,  because  her  menstruation  had 
ceased  for  eight  months,  her  abdomen  had  slowly  enlarged,  and 
so  had  also  her  breasts.  She  was  also  quite  sure  that  she  had 
6 


82  DISEASES   OF   THE   OVARIES. 

often  felt  movements,  and,  indeed,  had  all  the  feelings  that  she 
had  experienced  in  each  of  her  seven  pregnancies.  One  day, 
when  walking  in  the  street,  she  was  seized  with  pains,  exactly- 
like  labor-pains,  and  these  lasted  for  four  hours.  At  these  pains 
she  felt  no  surprise,  fully  believing  that  she  was  in  labor.  She 
felt  as  if  a  child  was  about  to  pass  from  her,  and  was  aware  of 
the  "■  swelling  pressing  downward."  She  afterward  felt  this 
"pass  back  into  the  belly,"'  the  pains  ceased,  and  her  size  re- 
mained unaltered.  At  this  false  labor  there  was  no  discharge. 
Up  to  the  time  when  I  first  saw  her  she  is  quite  certain  no  dimi- 
nution of  her  size  had  ever  occurred,  and  that  there  had  been 
very  little  increase,  if  any. 

The  physical  signs  of  the  case  were  those  of  multilocular  dis- 
ease of  both  ovaries,  and  on  them  I  need  not  dwell.  I  found  it 
was  so  when  I  operated,  and  the  operation  was  successful.  The 
lesson  of  the  case  is  that  we  should  place  very  little  confidence 
in  the  statements  of  patients,  if  they  are  not  in  harmony  with 
physical  signs.  I  must  plead  in  extenuation,  that  I  never  saw  a 
woman  farther  removed  from  any  taint  of  hysteria,  and,  being 
an  illiterate  woman,  there  could  have  been  no  cramming  up  of 
symptoms  from  books.  The  strongest  point  in  her  story  was  the 
arrest  of  menstruation  for  eight  months,  and  I  had  corroboration 
of  her  statement. 

The  weak  points  in  the  story  were  those  I  did  not  attach  suffi- 
cient weight  to,  and  they  were  those  alone  on  Avhich  we  ought 
to  place  any  reliance  whatever.  They  are,  that  she  had  no 
''show"  during  the  false  labor,  and  that  her  size  did  not  dimin- 
ish after  it.  Having  now  almost  exhausted,  I  believe,  the  litera- 
ture of  the  subject,  I  am  satisfied  that  these  two  circumstances 
are  invariable  in  extra-uterine  gestation  which  has  gone  past  the 
period.  The  first  is  due  to  the  general  excitement  and  conges- 
tion of  the  organs  involved,  specially  to  the  enlargement  of  the 
uterus,  which  is  always  present  to  some  extent ;  and  the  second, 
to  the  absorption  of  the  liquor  amnii  after  the  death  of  the  child. 
The  complete  arrest  of  menstruation  during  the  period  corre- 
sponding to  normal  pregnancy  is  far  from  being  a  constant  con- 
dition. But  even  though  it  were,  like  its  accompanying  signs, 
such  as  enlargement  of  the  breasts,  darkening  of  the  areolae, 
increase  of  Montgomery's  tubercles,  malaise,  vomiting,  etc..  it 
would  help  us  to  do  little  more  than  suspect  a  pregnancy.  Some- 
times there  is  metrorrhagia,  due  to  the  large  size  and  empty 
condition  of  the  uterus,  a  symptom  which  would  incline  us  to 
the  diagnosis  of  uterine  myoma.  After  the  death  of  the  child, 
auscultatory  signs  cannot,  of  course,  be  made  available;  though 
in  one  of  my  cases,  where  the  child  was  clearly  dead,  the  pla- 


ERRORS   OF   DEVELOPMENT   OF   OVARIES   AND    OVIDUCTS.      83 

cental  sound  was  heard  at  my  first  visit,  but  had  disappeared 
entirely  at  my  second,  ten  hours  afterward — a  set  of  signs  which 
tended  to  confirm  my  diagnosis. 

The  invariable  condition  of  the  uterus  in  extra-uterine  preg- 
nancy, whether  before  or  after  the  death  of  the  child,  is  that  it 
is  intimately  associated  with  the  tumor,  generally  in  front  of  it, 
movable  to  a  limited  extent,  always  enlarged  before  the  death 
of  the  child,  and  remaining  so  afterward  if  the  placenta  be  at- 
tached, as  it  generally  is,  to  the  posterior  surface  of  the  fundus. 
The  most  important  point  is  that  the  cervix  is  always  quite 
open— in  my  cases  almost  admitting  the  finger.  Under  such  cir- 
cumstances, if  a  fetal  heart  is  audible,  the  case  is  clear.  If  not, 
then  the  character  of  the  tumor  must  be  taken  carefully  into  ac- 
count. If  the  case  is  seen  soon  after  the  death  of  the  child,  the 
tumor  will  be  soft,  more  or  less  obscure  ballottement  will  be  felt 
in  it,  and  possibly  a  part  of  the  child  may  be  made  out  by  rectal, 
vaginal,  or  supra-pelvic  examination.  It  is  at  this  stage  that 
the  difficulty  between  extra-uterine  gestation  and  hsematocele 
will  occur.  Hsematoceles  are  not  all  formed  quite  suddenly.  I 
have  seen  several  cases  where  a  monthly  addition  was  made  to 
the  effused  blood.  In  one  such  case,  during  the  formation  of 
a  large  hsematocele,  menstruation  was  entirely  suspended,  or 
rather  its  external  indications  were.  The  tumor  subsequently 
suppurated  and  discharged  through  the  rectum,  and  for  a  while 
it  really  was  a  grave  question  to  decide  whether  it  was  a  suppu- 
rating hsematocele  or  the  suppurating  cyst  of  an  extra-uterine 
pregnancy.  I  made  an  exploratory  incision  into  it  from  the  va- 
gina, and  satisfied  myself  that  the  former  alternative  was  the 
correct  one,  and  it  is  now  in  process  of  cure.  Periodically  increas- 
ing retro-uterine  hsematocele  may  easily  be  mistaken  for  extra- 
uterine pregnancy  in  the  later  stages,  and  vice  versa. 

After  the  absorption  of  the  liquor  amnii,  the  character  of  the 
tumor  in  extra-uterine  pregnancy  alters  very  much.  The  uterus 
may  become  smaller  and  more  mobile,  and  parts  of  the  child  may 
be  felt,  especially  in  the  rectum,  such  a  sign  at  once  pointing  out 
the  nature  of  the  case.  This  will  be  particularly  evident  in  the 
instances  of  the  extra-peritoneal  variety.  These  prominences, 
and  likewise  the  "  bosselures/'  or  knobs  of  the  hands  and  feet, 
which  are  often  felt  above  the  pelvis,  may  be  closely  imitated 
by  the  small  nut-like  cysts  of  small  ovarian  tumors,  and  espe- 
cially by  the  hard  irregularities  of  dermoid  cysts.  These  re- 
semblances existed  in  the  case  I  have  narrated  above  to  a  con- 
siderable extent,  but  to  a  very  much  more  marked  degree  in 
another  patient,  where  I  removed  both  ovaries — one  dermoid — 
but  where  the  resemblances,  fortunately,  did  not  lead  me  astray. 


84  DISEASES   OF   THE   OVARIES. 

If  the  cyst  be  packed  down  in  the  pelvis,  the  deception  may  be 
great,  and  nothing  but  an  exploratory  incision  will  clear  up  the 
case.  I  would  strongly  recommend  that,  in  such  cases,  the  aspi- 
rator should  not  be  used.  In  a  joint,  or  in  the  pleura,  where  the 
conditions  between  which  diagnosis  has  to  be  made  are  limited 
in  number,  this  instrument  is  doubtless  of  great  use,  as  it  is  for 
treatment  as  well.  But  in  the  abdomen  and  pelvis  it  is  very  dif- 
ferent. The  aspirator  may  tell  you  a  tumor  contains  serum, 
blood,  or  pus,  but  that  helps  you  but  little  as  to  the  seat  of  the 
disease,  and  nothing  at  all  as  to  its  treatment.  Besides,  the  risk 
of  the  aspirator  is  great,  quite  as  great  as  the  risk  of  an  abdomi- 
nal section.  My  use  of  the  aspirator  in  my  special  line  of  prac- 
tice is  therefore  diminishing,  and  in  all  cases  of  abdominal  tumor, 
Avhere  there  seems  a  reasonable  prospect  of  doing  good  to  the 
patient,  I  open  the  abdomen  and  make  out  the  condition.  I 
have  never  had  to  regret  this  practice,  and  I  very  often  have  had 
reason  to  be  pleased  with  its  results. 

Slow-growing  cancer  of  an  ovary,  or  in  the  neighborhood  of 
the  uterus,  especially  behind  it,  might  be  difficult  to  diagnose  by 
physical  signs  from  extra-uterine  pregnancy  of  long  standing, 
but  the  history  would  here  greatly  help  us.  The  increase  w^ould 
probably  be  steady,  and  if  a  rapid  accession  to  the  growth  took 
place,  a  temperature  chart  would  settle  the  difficulty ;  for  the 
only  condition  which  could  induce  rapid  increase  of  the  cyst  of 
an  extra-uterine  pregnancy  is  suppuration,  and  this  would  tell 
its  story  on  the  chart  in  lines  that  could  not  be  mistaken.  Any- 
thing else  might  safely  be  set  down  as  cancer.  Fibro-cystic 
disease  of  the  uterus  could  be  determined  as  a  tumor  of  the 
uterus.  Phantom  pregnancy  can  always  be  dispelled  by  an  an- 
aesthetic. 

After  the  diagnosis  of  a  case  of  extra-uterine  pregnancy  has 
been  satisfactorily  determined,  the  question  arises,  What  is  to 
be  done  with  it  ?  If  the  child  is  still  alive  and  near  the  full  term, 
I  believe  it  to  be  our  duty  to  operate.  If  the  child  is  dead,  the 
propriety  of  operating  seems  to  me  quite  evident,  though  it  has 
been  disputed  by  so  eminent  an  authority  as  Mr.  Jonathan  Hutch- 
inson. Of  course  no  strict  rule  can  be  laid  down,  and  each  case 
must  be  decided  on  its  own  merits  ;  but  the  records  of  surgery 
are  so  full  of  instances  of  the  risks  which  such  cases  have  to  run 
when  suppuration  of  the  sac  occurs,  as  it  almost  always  does 
some  time  or  other,  that  I  think  we  are  in  most  instances  justi- 
fied in  operating.  Moreover,  the  surgical  principles  on  wliich 
the  operation  is  to  be  conducted  are  now  so  well  established,  and 
its  results  are  so  good,  that  the  opponents  of  the  operation  seem 
to  me  to  be  in  a  very  illogical  position  if  they  still  continue  to 


ERROKS    OF   DEVELOPMENT   OF   OVARIES   AND   OVIDUCTS.      85 

advocate  certain  other  surgical  proceedings,  of  which  the  results 
are  notoriously  bad.  Whether  the  child  be  dead  or  not,  the  steps 
of  the  operation  do  not  vary,  and  the  only  condition  which  would 
modify  my  procedure  would  be  a  certainty  that  the  foetus  had 
been  developed  outside  the  peritoneum,  in  the  layers  of  the  broad 
ligament.  There  can,  however,  be  no  certainty  of  this  until  after 
an  exploratory  incision  in  the  median  line  of  the  anterior  ab- 
dominal wall  has  been  made,  so  that  we  may  say  that,  in  every 
case,  abdominal  section  is  the  first  step;  and  here  the  same  strict 
precautions  must  be  observed  as  in  ovariotomy. 

After  the  peritoneum  has  been  opened,  a  careful  inspection 
of  the  relations  of  the  ovum  must  be  made,  for  the  further  steps 
■of  ihe  operation  will  differ  materially  according  to  the  nature  of 
these  relations.  If  the  child  is  loose  in  the  abdomen,  it  merely 
requires  careful  removal,  careful  avoidance  of  the  placenta,  and 
the  closure  of  the  wound  in  the  abdomen  save  at  the  lower  part, 
through  which  the  umbilical  cord  must  be  drawn,  and  which 
must  be  kept  open  for  the  passage  of  the  placental  debris  after 
it  has  separated,  through  a  wide  glass  drainage-tube  inserted 
for  the  purpose.  The  discharge  must  be  drawn  up  by  means  of 
a  syringe,  three  or  four  times  in  the  twenty-four  hours,  and  the 
cavity  occasionally  washed  out  with  a  five  or  ten  per  cent,  solu- 
tion of  sulphuret  of  potassium,  or  some  other  harmless  disin- 
fectant. 

If  the  foetus  is  found  in  a  sac  which  is  not  covered  by  peri- 
toneum, that  is,  which  is  not  formed  by  the  folds  of  the  broad 
ligament,  the  sac  must  be  carefully  opened  in  the  middle  line, 
emptied  and  cleaned  out  as  well  as  possible,  and  then  its  edges 
must  be  stitched  round  to  the  edges  of  the  wound  in  the  abdomi- 
wdl  wall,  so  as  to  close  the  peritoneal  cavity  as  well  as  possible. 
The  lower  part  of  the  wound,  communicating  with  the  sac  only, 
must  as  before  be  left  open,  and  through  it  the  cord  must  be 
brought  and  the  placental  debris  must  pass.  I  have  had  six  suc- 
cessful cases  of  this  kind,  most  of  which  are  recorded  in  detail 
in  the  "  Transactions  of  the  Royal  Medico-Chirurgical  Society.'' 
If,  however,  the  sac  be  found  to  be  covered  by  peritoneum,  that 
is,  if  the  case  is  one  of  the  extra-peritoneal  variety,  I  believe  that 
a  different  method  might  be  followed  if  possible.  In  such  a  case 
the  peritoneum  will  be  found  lifted  up  from  its  usual  relations, 
so  that  it  runs  on  to  the  walls  at  a  much  higher  level  than  is 
usual.  In  this  way  an  exit  for  the  foetus  by  way  of  the  vagina 
is  possible,  subject  to  certain  conditions,  which  are  that  the  pla- 
centa is  not  to  be  cut  through,  and  that  the  passages  must  be 
large  enough  to  allow  the  child  to  pass.  In  a  case  which  I  oper- 
ated on  by  removing  the  foetus  through  an  incision  from  the 


86  DISEASES   OF   THE   OVARIES. 

vagina,  behind  the  uterus,  everything  was  favorable;  but,  unfor- 
tunately, in  ignorance  I  removed  the  placenta,  and  the  result  was 
fatal.  If  these  conditions  are  not  possible,  then  the  foetus  must 
be  removed  from  above,  and  the  sac  must  be  treated  as  already 
described.  I  am  bound,  however,  to  say  that  I  am  not  in  any 
way  in  favor  of  vaginal  section.  I  have  never  resorted  to  it  but 
once,  in  the  case  before  alluded  to.  and  my  growing  experience 
makes  me  think  that  abdominal  section  is  in  every  case  prefera- 
ble. The  golden  rule  for  this  operation  is  to  avoid  touching  tlie 
placenta. 


CHAPTER    III. 

OOPHOEITIS  AND   PEKI-OOPHOKITIS  —  CIRKHOSIS   OF  THE 
OVAEY— ABSCESS   OF  THE   OVARY. 

Organes  genitaux  internes  de  la  femme.    Gtjerin.    Annales  de  Gynecologie.    V.  XII. 

Affections  de  I'aprareil  utero-ovarien.     Fourcauld.     Paris,  1879. 

Ovarien  bei  Scharlach.     Lebedinskt.     Cent,  fiir  Gynekolog-ie.     V.  I. 

Die  Krankheiten  der  Ovarien.     Olshausen.     Stuttgart,  1877. 

Ein  Pall  von  Abscessbildung.     Huffell.     Archives  f.  Gyn.     V.  IX. 

Balneotherapie  im  Entziindung  der  Ovarium.     Flechsig.     Schmidt's  Jahrbuch.    V. 

170. 
Veranderung  des  Ovarium  als  Ursache  d.  Sterilitat.    Banijl.    Schmidt's  Jahrbuch. 

V.  178. 
Augenschmerz  bei  Affectionen  der  Ovarium. 

Douleur  de  rovaire  chez  les  femmes  enceintes.     BuDlN.     Progres  Med.,  1879. 
Ovarian  Pain  during  Pregnancy.     Chaignot.     Med.  Kecord,  1879. 
Abscess  of  both  Ovaries.     Cullingworth.     Obstet.  Soc.  Trans. 
Pathology  of  the  Ovaries.     Mathews  Duncan.     Med.  T.  and  G.,  1875. 
Clinical  Lecture  on  Ovaritis.     Mathews  Duncan.     Med.  T.  and  G.,  1879. 
Ovarite  a  la  suite  d'une  rougeole.     Lize.     Annales  de  Gyn.     V.  V. 
Tubercles  des  ovaires.     Talamon.     Annales  de  Gyn.     V.  VI. 
Diagnosis  of  Subacute  Ovaritis.     Tilt.     Obstet.  Trans.     Vol.  XV. 
Chronic  Ovaritis.     Thomas.     New  York  Med.  Jour.     V.  XIX. 
General  Peritonitis — Ovaritis  with  Abscess.     Lusk.     Amer.  Jour,  of  Obstetrics,  Jan., 

1879. 
Uterine  and  Ovarian  Inflammation.     Tilt.     London,  1863. 
Ovarite.     C.  Darolles.     Paris,  1876. 

The  accession  of  puberty  alters  the  nutrition  of  the  ovary  to 
the  extent  that,  at  the  monthly  periods,  it  shares  in  the  general 
state  of  hypersemia  and  excitement  then  common  to  all  the 
sexual  organs,  and  the  whole  economy  seems  to  participate 
in  the  disturbance.  Normally,  this  change  takes  place  in  the 
fourteenth  or  fifteenth  year  of  life  in  this  country  ;  at  an  earlier 
date  in  hot  climates.  In  strong,  healthy  girls,  especially  those 
engaged  in  active  out-door  work — still  more  those  living  a  life  ap- 
proaching to  the  primitive  state — the  moliminal  change  is  effected 
without  suffering  ;  but  in  girls  brought  up  in  refinement,  of  deli- 
cate habit  and  strumous  parentage,  there  is  much  trouble.  As  a 
rule,  this  seems  to  be  due  to  the  onset  of  menstruation,  and  the 


88  DISEASES   OF   THE   O VARIES. 

other  signs  of  the  change  while  the  ovary  is  still  in  its  infantile 
or  incompletely  developed  condition  ;  that  is,  while  it  is  forming 
incomplete  cells,  whose  nuclei  are  incapable  of  fulfilling  their 
great  functions,  and  the  whole  mechanism  of  ovulation  is  out  of 
gear.  In  such  cases  we  find  that  the  menstrual  flux  comes  on 
either  at  irregular  times  or  in  insufiicient  quantity;  or  that,  if  it 
comes  regularly,  it  is  over-abundant,  and  it  is  alwaj^s  accom- 
panied by  severe  pelvic  pain. 

There  is  a  large  class  of  ovarian  disease  due  to  altered  hsemic 
nutrition  of  the  gland,  which  clinical  experience  proves  to  be  far 
more  common  than  pathological  investigation  has  yet  shown. 
Of  the  prime  factors  in  these  cases  we  are  as  yet  comparatively 
ignorant ;  but  the  opportunities  now  afforded  us  of  seeing  the 
actual  lesions  of  the  ovaries,  in  those  cases  where  they  are  re- 
moved for  diseases  other  than  large  cystoma,  are  rapidly  open- 
ing up  some  of  the  most  difficult  questions  of  ovarian  pathology. 
Until  two  or  three  years  ago,  when  Keith's  success  in  ovariotomy 
induced  us  to  extend  our  efforts  in  abdominal  surge rj^  we  knew 
no  more  of  those  obscure  diseases  of  the  ovary  which  make  the 
lives  of  so  many  women  burdensome,  than  was  afforded  by  the 
evidence  of  a  few  stray  post-mortem  examinations.  As  the  clin- 
ical histories  of  the  cases  in  which  these  examinations  were 
made  were  usually  entirely  absent,  it  is  not  sur^Drising  that  we 
knew  little  or  nothing  of  the  pathology  of  the  ovaries,  save  in 
the  instance  of  cystoma. 

So  far  as  my  own  experience  goes,  I  think  I  can  now  say 
with  confidence  that  I  know  a  great  deal  more  than  I  did  three 
years  ago,  not  only  of  the  pathology  of  the  ovaries,  but  how  to 
cure  the  sufferings  inflicted  by  their  diseases. 

I  propose  to  retain  the  division  of  the  diseases  of  the  ovaries 
due  to  alteration  in  the  liccmic  nutrition,  which  I  introduced 
nearly  ten  years  ago,  and  therefore  I  divide  them  into  three 
groups,  differing  probably  only  in  degree  of  severity,  save  in  the 
cases  where  acute  ovaritis  has  a  specific  origin.  They  are  :  1. 
Ovarian  hypersemia  ;  2.  Acute  ovaritis  ;  3.  Chronic  ovaritis. 

It  may  seem  a  metaphysical  refinement  to  make  a  distinction 
between  the  first  and  second  of  these  classes,  but  I  have  long 
satisfied  myself  that  it  actually  exists.  Ovarian  hypersemia  is 
the  result  of  an  over-sufficient  and  generally  precocious  ovarian 
activity,  and  is,  therefore,  the  converse  of  the  condition  1  have 
detailed  under  the  terms  amenorrha^a  and  dj^smenorrhoea.  It  is 
far  from  being  a  rare  affection,  and  is  invariably  well  marked 
in  its  history,  the  chief  detail  of  which  will  generally  be  found 
to  be  menorrhagia.  In  a  typical  case  which  I  liave  now  under 
my  care,  the  following  is  a  summary  of  the  facts  :    The  young 


OOPHOKITIS    AND    PEKI-OOPHOKITIS — ABSCESS    OF    OVARY.       89 

lady  is  the  child  of  parents  of  markedly  nervous  temperament, 
is  well-grown,  I  might  almost  say  prematurely  developed  in 
every  way,  and,  when  little  over  thirteen,  began  to  menstruate. 
From  the  beginning  her  periods  were  profuse,  and  at  first  pain- 
less. She  enjoyed  excellent  health  for  many  months  after  the 
accession  of  menstruation,  during  which  time  the  flow  continued 
profuse,  generally  lasting  for  six  days  or  a  week,  and  necessita- 
ting the  use  of  from  four  to  six  napkins  daily.  By  the  time  she 
was  fourteen  it  was,  however,  evident  that  her  health  was  suf- 
fering. She  became  listless,  sleepy,  fainted  when  at  her  lessons, 
gave  indications  of  loss  of  memory,  and,  when  I  saw  her  first, 
she  was  decidedly  anaemic.  At  that  time  it  wanted  but  two  or 
three  days  before  the  accession  of  her  period,  and  steady  pres- 
sure over  the  ovaries  gave  her  great  pain,  which  she  described 
as  turning  her  quite  sick.  During  menstruation  this  pain  was 
induced  by  less  pressure,  but  in  the  intermenstrual  period  it 
could  not  be  produced  at  all.  She  always  seemed  better  in 
health  during  the  flow,  and  it  was  tliis  very  common  peculiarity 
that  prevented  her  parents  from  applying  earlier  for  the  much- 
needed  advice. 

In  such  a  case  there  cannot  be  a  doubt  that  there  is  hyperse- 
mia,  not  only  of  the  ovary,  but  of  the  whole  sexual  apparatus, 
due  to,  it  may  be,  or  more  probably  only  accompanying,  the 
increased  ovarian  activity.  This  of  itself  is  not  a  source  of  dan- 
ger, for  that  lies  in  the  menstrual  loss  producing  anaemia.  I 
have  not  yet  had  an  experience  sufficiently  extended  to  trace 
such  a  case  throughout  its  course  ;  but,  meeting  with  many  in- 
stances which  I  have  had  reason  to  regard  as  identically  of  the 
same  nature  in  later  stages,  I  believe  that  their  menstrual  his- 
tory is  much  the  same  as  that  of  other  women  after  they  have 
had  a  child,  the  process  of  gestation  seeming  to  rectify  in  great 
measure  the  abnormal  excitement.  If  they  remain  unmarried, 
they  go  on  suffering  from  menorrhagia,  become  extremely  anae- 
mic, and  have  the  menopause  at  the  usual  time,  but  marked 
with  abnormal  profuseness,  as  might  be  expected.  I  have  re- 
peatedly had  occasion  to  observe  that  marriage,  even  without 
resulting  pregnancies,  often  seems  to  do  good  in  the  way  of 
modifying  the  monthly  hemorrhage.  In  other  cases,  however, 
marriage  seems  to  make  them  very  much  worse,  to  induce 
chronic  ovaritis,  displacement  of  the  ovaries,  and  finally  to 
destroy  their  health  entirely. 

The  treatment  of  such  cases  should,  if  possible,  be  begun  in 
the  first  stage.  There  is  no  cause  of  deteriorated  general  health 
so  certain  for  a  young  woman  as  profuse  menstruation  due  to 
ovarian  hypersemia.     The  spansemic  condition  induced  by  a  few 


90  DISEASES    OF   THE   OVARIES. 

years'  continuation  of  it  is  one  over  which  iron  seems  to  have  no 
control  ;  indeed,  all  ferruginous  preparations  ought  to  be  sedu- 
lously avoided  until  the  nienorrhagia  has  completely  ceased. 

In  the  cases  such  as  I  have  narrated,  my  first  advice  is  that 
the  patient  should  be  removed  from  school ;  and  that,  for  six 
months,  all  instruction,  especially  in  music,  should  cease.  I 
notice  music  especially,  for  I  am  quite  certain  that  instruction 
in  that  art,  as  carried  out  in  boarding-schools,  has  to  answer  for 
a  great  deal  of  menstrual  mischief.  To  keep  a  young  girl,  dur- 
ing her  first  efforts  of  sexual  development,  seated  upright  on  a 
music-stool,  with  her  back  unsupported,  drumming  vigorously 
at  a  piano  for  several  hours,  can  only  be  detrimental.  It  is  usu- 
ally the  habit  of  those  who  superintend  the  education  of  girls  to 
make  no  difference  whatever  in  their  physical  and  mental  exer- 
cises during  their  menstrual  periods  ;  and,  at  a  time  when  the 
great  necessity  of  the  system  is  perfect  rest,  laborious  efforts 
have  to  be  made.  This  is  most  pernicious,  and  I  have  repeatedl}' 
had  to  trace  to  it  the  existence  of  serious  disease  in  young  ladies. 
Musical  exercises  are  especially  hurtful,  for  the  further  reason 
that  music,  in  those  who  are  devoted  to  it  and  gifted  with  its 
necessary  peculiarities,  is  a  strong  excitant  of  the  emotions  ; 
while  to  those  not  so  gifted,  and  who  do  not  care  for  it,  nmsical 
exercises  are  an  intolerable  and  useless  burden.  Absolute  rest 
is  an  essential  part  of  the  treatment  of  the  early  stage  of  ovarian 
hyperaemia,  and  I  need  scarcely  say  that  it  is  in  its  early  stage 
that  the  treatment  is  most  likely  to  be  successful.  This  rest 
ought  to  1)6  rigorously  carried  out  by  the  patient  being  confined 
to  the  i^rone  position  for  a  few  days  before,  during,  and  for  a 
few  days  after,  the  catamenial  flow.  The  application  of  a  coun- 
ter-irritant over  the  ovarian  region,  just  before  the  period,  is 
very  useful  ;  but  the  most  potent  part  of  the  treatment  consists 
in  the  administration  of  ergot  before  and  during  the  period,  and 
of  the  salts  of  potassium  continuously  during  the  intermenstrual 
time.  The  ergot  is  best  given  in  the  form  of  ergotin.  my  favorite 
formula  being  half  a  grain  of  Bonjean's  ergotin  made  into  a  pill 
with  sufficient  lupulin.  Tlie  bromide  I  give  night  and  morning, 
after  meals,  in  doses  from  five  to  ten  grains.  There  is  a  great 
deal  to  be  done  in  moral  treatment.  It  may  be  only  a  coinci- 
dence, but  I  have  noticed  this  affection  chiefly  in  girls  who  have 
had  no  brothers,  or  brothers  only  younger  than  themselves  :  and 
I  am  quite  certain  that  great  harm  is  done  to  many  girls  by  their 
rigid  social  seclusion,  in  youth,  from  the  companionship  of  boys. 
Under  proper  supervision,  no  wrong  could  hai)pen  from  more 
unrestricted  association  of  1)03"S  and  girls  at  their  critical  periods; 
and  it  seems  to  me  that  it  is  a  mischievous  i)lan  to  draw  wide 


OOrilOllITIS    AND    PERI-OOPHOTIITIS — ABSCESS    OF    OVAKY.       91 

barrier-lines  between  the  sexes  at  a  time  when  they  ought  to 
begin  to  understand  themselves  and  each  other  ;  and,  by  harm- 
less intercourse,  many  of  the  risks  may  be  obviated  which  after- 
ward beset  them  when  an  unaccustomed  association  is  opened 
out  at  an  age  when  instinct  has  the  chief  ascendancy. 

While  upon  this  subject,  I  should  neglect  my  duty  were  I  to 
refrain  from  speaking  on  another  subject  concerning  the  educa- 
tion of  girls.  There  has  grown  up  a  desire  to  educate  women  in 
exactly  the  same  way  and  to  the  same  extent  as  men.  It  would 
be  easy  for  me  to  show,  were  any  charge  of  obstructiveness  or 
want  of  liberality  to  be  made  against  me,  that  throughout  my 
public  life  I  have  ever  been  in  the  front  rank  of  those  who  advo- 
cate perfect  freedom  of  every  kind  of  instruction  for  every  one 
who  may  desire  it ;  and  I  have  been  particularly  strong  in  the 
expression  of  my  views  that  there  should  be  restriction  of  neither 
class  nor  sex.  But  it  is  useless  to  disguise  the  fact  that,  inas- 
much as  women  have  functions  to  fulfil  which  men  are  free 
from,  it  is  not  to  be  expected  that  women  can,  with  safety,  do 
the  work  of  men,  and  at  the  same  time  properly  fulfil  their  own 
special  functions  as  women.  The  questions  raised  by  the  ad- 
vanced advocates  of  women's  rights  are  to  be  settled,  not  on  the 
platform  of  the  political  economist,  but  in  the  consulting-room 
of  the  gynecologist.  This  is  no  place  to  air  political  crotchets, 
but  I  may  own  myself  an  advanced  advocate  of  women's  rights  ; 
at  the  same  time  I  cannot  help  seeing  the  mischief  women  will 
do  to  themselves,  and  to  the  race  generally,  if  they  avail  them- 
selves too  fully  of  these  rights  when  conceded.  It  may  be,  and 
probably  is,  a  very  gratifying  circumstance  for  a  young  woman 
to  go  to  a  college,  and  show  that  she  could  take  as  high  a  de- 
gree as  a  man  ;  but,  considering  the  fact  that  she  has  a  monthly 
disturbance,  she  would  take  this  degree  at  a  price  which  a  man 
would  not  have  to  pay  for  it.  To  fulfil  the  necessary  conditions 
she  will  tax  herself  to  such  an  extent  as  will,  in  all  probability, 
make  her  functions  imperfect.  To  continue  the  career  begun 
at  college,  she  must  deny  herself  the  congenial  occupations  of  a 
wife  and  the  pleasures  of  maternity,  and  thus  she  robs  the  hu- 
man race  of  what  it  wants  most,  brain-power  on  the  part  of  the 
mother.  To  leave  only  the  inferior  women  to  perpetuate  the 
species  will  do  more  to  deteriorate  the  human  race  than  all  the 
individual  victories  at  Girton  will  do  to  benefit  it.  This  over- 
training of  young  women  is  wholly  unnecessary  in  the  interests 
of  human  progress,  and  it  is  mischievous  alike  to  themselves 
and  to  humanity.  To  hear  an  elderly  maiden  lady  read  a  learned 
paper  on  mathematics  may  be  a  gratifying  circumstance,  but 
it  is  largely  qualified  by  regrets  when  we  speculate  what  supe- 


92  DISEASES    OF   THE    OVARIES. 

rior  children  she  might  have  produced  if  she  had  been  a  little 
less  learned  in  books.  Those  who  advocate  the  equal  treatment 
of  the  sexes  must  bear  in  mind  that  great  culture  in  a  man  does 
not  unfit  him  for  paternity,  but,  on  the  contrary,  will  help  him, 
in  the  struggle  for  existence,  to  maintain  a  family.  For  women, 
on  the  contrary,  exceptional  culture  will  have  infallibly  the 
tendency  to  remove  the  fittest  individuals,  those  most  likely  to 
add  to  the  production  of  children  of  high  class  brain-power, 
from  out  of  the  rank  of  motherhood. 

All  the  cases  of  ovarian  hypei-semia  which  I  have  met  with 
at  puberty  have  yielded  to  the  treatment  I  have  detailed,  and 
many  cases  which  I  have  had  reason  to  regard  as  of  this  nature, 
but  in  a  later  stage,  have  been  benefited  by  it.  It  is,  however, 
in  the  perfect  fulfilment  of  the  function  of  the  utero-ovarian  or- 
gans that  we  have  the  radical  cure. 

Ovarian  hypersemia  is  sometimes  met  with  as  the  result  of 
marriage,  especially  when  the  marital  acts  have  been  indulged 
in  to  excess,  and  particularly  when  pregnancy  has  not  resulted. 
This,  in  fact,  is  only  the  mildest  form  of  a  serious  disease  w^hich 
may  end  in  total  inflammatory  disorganization  of  the  ovaries  of 
newly  married  women.  It  is  not  unusual  to  find  a  delicate  wo- 
man, who  had  menstruated  normally  previous  to  her  marriage, 
suffer  from  severe  raenorrhagia  for  the  first  three  or  four  years 
of  married  life,  and  to  find  an  explanation  of  this  in  the  vigor  of 
the  husband.  In  these  cases  ovarian  tenderness  is  always  pres- 
ent, and  very  frequently  there  is  violent  pain  and  tenesmus, 
lasting  for  liours  after  connection,  so  that  soon  the  unfortunate 
sufferer  dreads  the  idea  of  a  marital  embrace.  The  menstrual 
period  becomes  prolonged,  so  that  there  is  left  only  an  intermen- 
strual interval  of  a  few  days.  In  prostitutes  of  a  tender  age  this 
affection  is  of  extreme  frequency,  and  often  ends  in  the  chronic 
ovaritis  with  adhesion  of  the  Fallopian  fimbriae  to  the  ovary, 
and  the  subsequent  atrophy  of  all  the  sexual  structures  so  often 
found  in  their  bodies.  The  recurrent  inflammatory  attacks  thus 
induced  in  these  unfortunates  have  been  termed  colica  scorto- 
riivi.  The  cure  depends,  of  course,  on  the  removal  of  the  excit- 
ing cause  and  the  employment  of  such  treatment  as  has  been 
before  alluded  to,  but  in  severe  and  protracted  cases  it  will  be 
effected  only  by  removal  of  the  ovaries  and  tubes.  This  step  is 
to  be  resorted  to  only  after  the  failure  of  everything  else,  but 
many  times  I  have  been  obliged  to  adopt  it,  and  always  with 
the  best  results.  The  idea  that  removal  of  the  ovaries  will  un- 
fiex  a  woman  is  founded  on  ign<jrance.  So  far  as  maternity  is 
concerned,  it  of  course  destroys  the  function  completely  :  but 
that  has  already  been  done  by  the  disease  for  which  the  opera- 


OOPHORITIS    AND    PERT-OOPIIOTIITIS — ABSCESS    OF    OVARY.       93 

tion  has  been  performed.  A  woman  who  has  suffered  for  years 
from  chronic  ovaritis  with  adherent  tubes,  and  possibly  hydro- 
salpinx or  j)yo-salpinx,  is  necessarily  barren,  so  that  to  remove 
the  uterine  appendages  is  to  make  her  no  worse  than  she  was. 
But  such  a  disease  as  this  will  oblige  her  to  suspend  marital  re- 
lations, or  to  endure  them  only  as  a  matter  of  duty,  and  with 
great  suffering.  To  remove  the  diseased  structures  will  be  to 
enable  her  satisfactorily  to  perform  her  marital  duties,  and  the 
operation,  if  successful,  will  be  found  really  to  reinstate  her  in 
her  sexual  functions,  and  not  to  unsex  her. 

In  very  many  of  the  cases  of  which  I  now  speak,  no  line  can 
be  drawn  which  will  define  where  simple  hypersemia  ends  and 
acute  or  chronic  ovaritis  begins.  In  many  of  them  we  get  a 
distinct  history  of  an  acute  attack,  which  was  probably  ovari- 
tis, wliile  in  otliers  the  symptoms  came  on  gradually,  without 
any  noticeable  starting-point,  and  ovarian  hypersemia  probably 
in  these  passes  insensibly  into  chronic  ovaritis.  I  propose  here 
to  give  a  series  of  cases  illustrating  these  different  classes. 

E.  S was  a  young  married  lady,  whom  I  first  saw  in  May, 

1879,  with  Mr.  Arthur  Newton,  of  Newhall  Street.  Her  men- 
struation commenced  when  she  was  thirteen  years  of  age,  waS' 
always  so  painful  that  she  was  confined  to  bed  while  it  lasted, 
being  wholly  unable  to  get  about  or  sit  up.  This  pain  came  on 
invariably  two  days  before  the  period  lasted,  so  that  she  began 
her  sexual  life  with  diseased  ovaries.  She  was  married  in  1876, 
and  marriage  made  her  very  much  worse.  She  became  pregnant 
in  three  months,  and  it  was  hoped  that  this  would  cure  her,  but 
it  did  not.  After  her  confinement  she  had  an  acute  attack  of 
pelvic  peritonitis,  which  seems  to  have  been  a  very  serious  ill- 
ness. She  became  pregnant  again,  and  was  confined  in  January, 
1879,  and  had  another  inflammatory  attack,  and  from  that  time 
she  was  never  out  of  bed  till  after  the  recovery  from  the  ovari- 
otomy which  I  performed  on  her  on  February  9,  1880. 

I  saw  her,  as  I  have  said,  first  in  May,  1879,  and  I  then  found 
the  fundus  very  large  and  retroverted,  with  the  ovaries  also 
much  enlarged,  extremely  tender,  and  lying  down  below  the 
fundus.  She  could  bear  no  kind  of  pessary;  the  menstruation 
was  regular  and  profuse,  and  the  pain  during  its  continuance 
amounted  to  agony.  I  advised  blistering,  morphia,  pessaries. 
and  the  abundant  administration  of  bromide  of  potassium  and 
ergot.  This  treatment  had  no  effect,  nor  had  the  efforts  of  an- 
other specialist  under  whose  care  she  was  afterward  placed.  I 
saw  her  again,  with  Mr.  Newton,  in  January,  1880,  and  found 
her  condition  much  worse.     She  had  all  the  old  symptoms,  but 


94  DISEASES   OF  THE   OVARIES. 

in  addition  she  was  feverish,  worn,  and  hectic.  Everything  had 
been  tried  and  had  failed,  and  ovariotomy  only  remained.  To 
this  Mr.  Newton  agreed,  and  so  did  the  patient,  her  husband, 
and  friends.  I  found  both  ovaries  adherent  in  the  cul-de-sac, 
and  much  care  had  to  be  exercised  in  detaching  them.  They 
were  very  soft,  greatly  enlarged,  and  covered  with  lymph.  She 
made  an  uninterrupted  recovery,  and  got  up  on  March  5th.  On 
April  1st  she  walked  about  the  house  for  the  first  time  in 
eighteen  months,  and  had  gained  greatly  in  every  respect.  On 
July  20th  she  was  able  to  walk  a  mile,  and  had  got  quite  stout, 
was  entirely  free  from  pain,  marital  relations  had  been  resumed 
with  perfect  satisfaction,  and  this,  as  she  frankly  told  me,  for  the 
first  time  in  her  life.  On  September  9th  I  saw  her  get  down 
without  assistance  from  a  high  dog-cart,  and  run  briskly  up 
some  steps,  as  if  she  had  never  ailed.  She  has  not  had  the 
slightest  appearance  of  menstruation  since  the  operation,  and 
the  climacteric  disturbance  is  quite  over  (February,  1881),  and 
she  is  in  perfect  health. 

The  patient,  her  friends,  her  attendant  Mr.  Newton,  are  all 
quite  as  well  satisfied  as  I  am  with  the  result  of  this  case,  and 
that  nothing  short  of  ovariotomy  would  have  saved  her  life. 
The  only  thing  I  regret  is  that  I  did  not  operate  many  months 
earlier  than  I  did.  In  this  case  the  patient  probably  suffered 
from  ovarian  hypersemia  during  the  whole  of  her  menstrual  life, 
and  this  was  transformed  into  chronic  ovaritis  by  an  acute  at- 
tack in  the  puerperal  state. 

On  February  20, 1880,  a  lady  was  brought  to  me  from  London, 
who  had  been  confined  to  the  recumbent  position  for  seven  years, 
and  to  bed  absolutely  for  nearly  four  years.  Her  menstruation 
began  at  twelve  years  of  age,  was  not  very  regular,  and  was 
always  accompanied  by  pain.  It  continued  much  the  same  till 
she  was  about  twenty-eight  years  of  age,  when  she  had  an  ill- 
ness, and,  ever  since,  the  pain  during  menstruation  has  been 
much  more  severe,  and  had  become  progressively  so  for  the  last 
nine  years.  During  the  four  years  she  had  been  under  the  care 
of  Dr.  Graily  Hewitt,  and  had  undergone  prolonged,  careful, 
and  various  treatments  by  pessaries,  etc. ,  but  without  the  slight- 
est benefit ;  in  fact,  she  got  continuously  worse.  When  I  first 
saw  lier,  the  history  was  given  that  menstruation  was  perfectly 
regular,  lasting  from  six  to  eight  days,  and  was  very  profuse. 
Just  before  the  period  severe  pain  came  on,  and  lasted,  with 
slight  intermission,  the  whole  time.  The  pain  in  her  back  was 
incessant,  and  utterly  prevented  her  walking.     I  found  the  ute- 


OOPJIOKITIS   AND    PEKI-OOPIIOIUTIS — ABSCESS    OF    OVARY.       9.") 

rus  quite  bent  upon  itself  backward,  and  so  retroverted  as  to  be 
almost  turned  upside  down.  The  fundus  was  very  large  and 
soft,  and  the  ovaries,  much  enlarged,  were  alongside  and  below 
it.  The  organs  were  so  excessively  tender  that  without  ether 
examination  was  impossible,  so  that  I  am  not  surprised  no  pes- 
sary could  be  endured. 

I  explained  to  the  lady  and  her  friends  that  the  conditions 
were  such  that  no  effort  at  rectification  by  pessary  need  be  at- 
tempted ;  that,  if  Dr.  Hewitt  had  failed,  I  was  not  likely  to  suc- 
ceed ;  and  that  the  radical  cure  of  ovariotomy  was  the  only  one 
which  promised  success.  This  they  accepted,  and  I  performed 
the  operation  on  the  2Gth.  The  ovaries  were  enormously  en- 
larged, but  not  cystic  ;  the  fundus  was  soft  and  spongy,  and 
nearly  three  times  the  size  it  ought  to  be  in  a  virgin.  There 
were  no  adhesions.  After  removing  the  ovaries,  and  whilst 
closing  the  wound,  I  passed  a  stitch  through  the  fundus,  and 
fastened  it  up  to  the  abdominal  wall.  She  recovered  per- 
fectly, has  never  menstruated  since,  is  getting  fat  and  well, 
and  can  now  walk  about  the  house  and  garden.  The  re- 
covery of  her  power  of  locomotion  is  slow,  but  steady,  and  I 
need  hardly  say  that,  after  seven  years  of  their  suspension,  we 
can  hardly  expect  any  very  rapid  progress.  The  uterus  is  now 
perfectly  straight  and  normally  hung,  and  it  is  quite  of  the 
senile  size. 

The  next  case  was  that  of  a  lady,  aged  thirty-three,  who  be- 
gan to  menstruate  at  thirteen,  was  married  at  twenty,  and  in 
eleven  years  had  seven  children.  Her  first  child  was  born  prema- 
turely, and  she  had  never  been  well  since,  for  she  got  up  and  un- 
dertook a  railway  journey  on  the  fourteenth  day.  After  this  she 
had  continuous  hemorrhage  for  several  months.  She  had  sev- 
eral premature  and  dead  children  after  this,  and  then  one  living 
child,  and  the  seventh  dead.  Three  years  previous  to  my  seeing 
her  she  consulted  a  distinguished  metropolitan  specialist,  who, 
upon  his  consulting-room  couch,  "  did  something  to  her  which 
gave  her  immediately  a  violent  pain  in  the  back,"  and  that  pain 
she  never  lost  for  an  hour,  save  when  asleep  or  narcotized,  till 
the  day  I  operated  upon  her.  V/hat  this  was  which  was  done  to 
her,  of  course  I  do  not  know,  though  I  have  little  doubt  it  was  the 
rectification  of  her  remarkable  retroversion  by  the  sound.  If  it 
was,  it  is  another  example  which  we  may  quote  against  this 
mischievous  practice.  "When  I  first  saw  her  I  got  the  story  that 
ever  since  this  incident  the  patient's  life  was  a  misery  to  her  and 
her  surroundings — that  she  could  not  get  about — was  on  the 
couch  all  day  long — her  menstruation  so  protracted  and  profuse 
that  it  lasted  quite  half  the  month — and  she  had  hardly  recov- 


96  DISEASES    OF   THE   OVARIES. 

ered  from  the  exhaustion  consequent  upon  the  loss  and  the  in- 
crease of  her  sufferings  when  she  was  ill  again.  She  had  been 
under  the  hands  of  quite  a  number  of  speciahsts  both  here  and 
in  London ;  and  after  reading  up  her  case,  and  comparing  the 
opinions  expressed  about  it,  and  having  come  across  one  of  my 
cases  of  spaying,  she  came  to  me  deUberately,  to  ask  me  if  I 
thought  I  could  spay  her,  and,  if  I  could,  if  I  thought  it  would 
do  her  good.  She  had  been  told  that  the  womb  was  bent  back- 
ward, but  that  tliere  was  a  tumor  on  either  side  of  it.  The  tu- 
mors in  question  I  found  to  be  enormously  enlarged  and  very 
tender  ovaries  lying  behind  and  below  a  retroflected  and  retro- 
verted  fundus,  Avhich  felt  so  large  that  it  really  might  have  been 
a  question  whether  or  not  there  was  a  myoma  in  it.  From  my 
previous  experience,  I  was  of  opinion  that  fundal  enlargement 
was  due  merely  to  chronic  fundal  metritis,  though  I  was  quite 
prepared  to  find  a  myoma  at  the  operation. 

I  had  no  difficulty,  in  such  a  case  as  this,  in  recommending 
the  removal  of  the  ovaries,  for  the  mere  names  of  the  gentlemen 
under  whose  care  she  had  previously  been,  without  benefit,  were 
sufficient  guarantee  that  everything  short  of  that  had  been  tried. 
Moreover,  the  patient,  a  clever,  intelligent  woman,  knew  all 
about  her  case,  and  told  me  pretty  accurately  all  that  had  been 
done.  I  had,  besides,  the  advantage  of  the  history  given  by  one 
of  her  medical  attendants. 

The  immediate  arrest  of  the  hemorrhage,  which  had  been  un- 
controlled even  by  hypodermic  injection  of  ergotin,  would  alone 
have  been  a  sufficient  warrant  for  the  ovariotomy,  but  there 
were  numerous  other  reasons  in  its  favor,  I  therefore  performed 
it  on  April  9th,  and  found  the  fundus  enlarged  from  chronic  fun- 
dal metritis  only,  the  ovaries  enlarged  from  chronic  interstitial 
inflammation,  and  the  displacement  as  I  have  described  it.  I 
removed  the  ovaries  «i.nd  stitched  the  uterus  up  to  the  wound  as 
in  the  previous  case.  She  made  an  uninterrupted  recovery,  and 
has  never  menstruated  since.  She  is  now  full  of  color,  stout, 
and  well  in  every  respect  but  one.  She  went  through  the  early 
stage  of  the  climacteria  without  much  suffering,  and  these  dis- 
agreeables are  passing  off  rapidly.  For  six  weeks  after  the  oper- 
ation she  was  absolutely  free  from  the  terrible  pain  in  the  back  ; 
but  as  she  began  to  get  about  it  came  back,  and  for  a  time  was 
as  bad  as  ever,  despite  the  uterus  being  absolutely  normal  in 
position  and  speedily  regaining  its  normal  size.  This  pain  in 
the  back  still  continues  in  a  modified  form,  and  is,  I  believe, 
slowly  fading  away  ;  and  I  have  not  the  least  doubt  it  will  en- 
tirely disappear  in  time.  Why  it  has  returned,  and  why  it  has 
lingered  so  long,  I  do  not  know,  for  there  is  no  physical  reason 


OOPHORITIS    AND   PERI-OOPIIORITIS — ABSCESS   OF   OVARY.      97 

for  it  perceptible.     In  every  other  respect  the  results  of  the  oper- 
ation fully  justify  its  performance. 

In  very  many  cases  such  as  these,  there  will  be  found  no  inci- 
dent in  the  history  from  which  it  can  bo  said  that  ovarian  hyper- 
semia  was  transformed  into  chronic  ovaritis.  In  others  a  distinct 
history  can  be  given  of  an  acute  attack,  from  which  the  chronic 
suffering-  can  be  dated  ;  and  my  belief  is  that  the  two  classes 
may  be  more  carefully  defined  by  further  observation,  and  that 
their  pathological  features  are  wholly  different. 

So  far  as  I  know,  acute  ovaritis  is  the  result  of  four  condi- 
tions only  : 

1.  Injury; 

2.  Gonorrhoeal  infection  ; 

3.  Septic  poisoning  in  the  parturient  condition  ; 

4.  Exanthematic  fevers  and  acute  rheumatism. 

In  one  woman  I  diagnosed  acute  ovaritis  following  injuries 
inflicted  by  her  paramour  kicking  her  ;  and  though  it  may  have 
been  general  pelvic  peritonitis,  yet  the  uterus  never  became 
fixed  as  it  does  in  that  condition,  and  the  subsequent  permanent 
disturbance  of  menstruation,  accompanied  by  other  signs  of 
chronic  ovaritis,  confirmed  me  in  my  opinion. 

Acute  ovaritis  from  gonorrhoea  is  a  common  result  of  the  in- 
fection, and  is  a  frequent  cause  of  sterility.  It  seems  to  be  pre- 
cisely similar  to  the  acute  epididymitis  of  the  male,  as  was  first 
pointed  out  by  Bernutz  and  Victor  de  Meric.  In  this  affection 
the  patient  is  found  with  an  anxious  face,  agonizing  pelvic  pain, 
generally  only  on  one  side,  the  knees  drawn  up,  and  all  the 
signs  of  a  severe  inflammatory  attack.  The  patient  can  lie  with 
comfort  only  on  the  back,  and  micturition  and  defecation  are 
productive  sometimes  of  excruciating  pain.  It  is  often  impossi- 
ble to  make  a  vaginal  examination  without  an  anaesthetic,  and 
this  had  better  be  used  at  once,  for  it  is  a  matter  of  consequence 
to  diagnose  between  acute  ovaritis  and  pelvic  cellulitis.  In  the 
latter  the  tumor  will  be  found  attached  to  the  uterus,  and  mov- 
ing with  it  and  with  the  whole  roof  of  the  pelvis,  and  will  be 
found  to  be  more  or  less  fixed  ;  while  in  ovaritis  the  enlarged 
ovary  may.  as  a  rule,  easily  be  made  out.  The  treatment  should 
consist  in  leeches  to  the  perineum,  a  blister  over  the  ovary,  diu- 
retics, and  small,  frequent  doses  of  opium.  The  rectum  should 
be  well  evacuated  by  an  enema,  and  the  bowels  kept  quiet  for  a 
few  days.  The  great  risk  of  the  disease  is  that  of  its  spreading 
into  general  peritonitis.  In  the  event  of  the  attack  appearing  to 
threaten  the  life  of  any  patient  under  my  care.  I  would  not  hesi- 
tate to  open  the  abdomen,  cleanse  out  the  cavity,  and  possibly 
7 


98  DISEASES    OF   THE   OVAKIES. 

remove  the  diseased  organs.  When  an  ovarian  tumor  is  gan- 
grenous or  suppurating,  we  serve  the  patient  by  promptly  re- 
moving it,  and  I  do  not  see  why  this  principle  should  not  be  ex- 
tended. The  result  of  the  disease  is  nearly  always  to  destroy 
the  functions  of  the  glands,  and  therefore,  in  prospect  of  a  fatal 
issue  of  the  disease,  the  argument  against  an  operation,  that  it 
will  unsex  the  j)atient,  need  not  be  considered. 

Gonorrhoeal  ovaritis  is  an  extremely  treacherous  disease,  or 
rather,  perhaps  I  ought  to  say  that  gonorrhoea  is  a  disease  which 
in  women  may  be  fraught  with  the  most  serious  and  unexpected 
consequences.  Some  years  ago  a  gentleman  wiio  had  been  a 
short  time  married,  visited  a  neighborhood  where  he  unfortu- 
nately met  a  friend  of  his  bachelor  days.  Within  forty-eight 
hours  he  came  to  me  in  terrible  distress,  wjth  the  initial  symp- 
toms of  gonorrhoea,  but  "with  the  still  more  terrible  dread  that 
he  might  have  conveyed  it  to  his  wife,  for  intercourse  had  taken 
place  a  few  hours  before  his  symptoms  appeared.  Of  course  I 
at  once  cautioned  him  to  refrain  absolutely  from  intercourse 
with  his  wife— advice  which  I  have  no  reason  to  believe  that  he 
disregarded.  His  gonorrhoea  proved  very  trifling,  and  passed 
off  entirely  in  less  than  a  week.  Wishing  to  take  his  annual 
holiday,  he  brought  his  wife  to  me  to  make  sure  that  she  was 
free  from  disease,  and  I  could  not  find  the  slightest  trace  of  va- 
ginitis. I  therefore  sanctioned  their  travelling  to  a  considerable 
distance.  But  within  three  days  I  was  summoned  to  her,  and 
found  her  suffering  from  a  most  severe  attack  of  inflammation 
of  the  left  ovary.  Aftei'  some  weeks  she  got  well,  though  the 
ovary  could  be  felt,  both  by  rectum  and  vagina,  as  large  as 
a  small  orange,  firmly  fixed  and  exquisitely  tender.  Suddenly 
the  right  ovary  became  similarly  affected  ;  and  after  a  most  se- 
vere illness,  during  which  she  seemed  frequently  at  the  point  of 
death,  she  recovered,  with  the  right  ovary  similarly  enlarged 
and  fixed.  She  never  menstruated  after  this  second  illness,  and 
she  now  lives  a  semi-invalid  life,  hardly  ever  free  from  pain, 
and  unfit  for  any  great  exertion,  though  as  time  goes  on  her  suf- 
ferings seem  to  obtain  slight  amelioration.  She  is  quite  unable 
to  endure  marital  intercourse,  and  the  best  thing  that  could  be 
done  for  her  would  be  removal  of  the  uterine  appendages.  She 
belongs,  however,  to  the  better  ranks  of  life,  and  we  find  that 
patients  of  this  class  very  often  prefer  a  chronic  invalidism  to 
the  risks  of  an  operation.  They  can  pay  for  any  amount  of  lux- 
ury and  medical  attendance,  and  they  do  what  is  best  for  their 
doctors  in  a  pecuniary  sense,  but  not  what  is  best  for  themselves. 

The  history  of  such  a  case  is  undoubtedly  that  the  poison  has 
permeated  the  uterus  and  Fallopian  tubes,  alighting  on  the  ovary 


OOPHORITIS   AXD   PERI-OOPHORITIS — ABSCESS   OF   OVARY.      99 

from  the  tube  probably  at  the  time  that  the  fimbriae  were  in  as- 
sociation with  it ;  but  it  is  somewhat  surprising  that  there  was 
never  any  trace  of  vaginitis. 

A  case  of  alternating  ovaritis,  for  which  I  have  been  unable 
to  discover  any  cause,  has  been  for  some  time  under  my  care  in 

hospital  practice.     The  patient,  J.  K ,  aged  twenty-five,  came 

to  the  hospital  with  well-marked  acute  inflammation  of  the  left 
ovary.  She  had  been  married  for  three  years,  and  had  never 
been  pregnant.  There  was  nothing  in  her  history  to  make  me 
suspect  that  she  had  suffered  from  gonorrhoea,  nor  did  she  know 
of  her  husband  having  so  suffered.  The  left  ovary  recovered  in 
a,  few  weeks,  but  remained  somewhat  enlarged  and  very  tender, 
and  it  was  also  somewhat  fixed.  In  about  two  months  she  came 
back  with  the  right  ovary  quite  as  severely  involved,  and  has 
since  been  several  times  under  care  with  recurrences  on  one  or 
other  side  ;  but  both  ovaries  have  never  been  attacked  together, 
and  none  of  the  attacks  have  been  assoeiated  with  menstruation, 
which,  always  irregular,  has  been  gradually  getting  rarer  and 
more  scant.  The  most  probable  explanation  of  this  curious  case 
is,  that  she  is  exposed  every  now  and  then  to  some  infection 
which  travels  up  her  Fallopian  tubes,  and  attacks  the  ovaries 
without  giving  any  indication  elsewhere  of  its  presence.  The 
possibility  of  such  an  event  must  always  be  borne  in  mind,  and 
as  a  guide  to  future  directions  it  may  be  advisable  to  ask  cau- 
tiously into  the  history  of  an  attack  of  acute  ovaritis.  Whatever 
be  the  explanation,  it  must  ever  be  borne  in  mind  that  ovaritis 
is  a  disease  peculiarly  liable  to  relapses,  and  cautions  upon  this 
point  must  be  given  to  the  patient. 

Of  acute  ovaritis  in  childbed  from  septic  causes,  as  distin- 
guished from  general  septic  peritonitis  in  which  the  ovary  is 
involved,  my  experience  is  limited  to  one  case  in  which,  like 
those  recorded  by  Simpson,  Bernutz,  and  others,  an  abscess  re- 
sulted. The  infection  occurred  after  a  miscarriage  in  the  wife 
of  a  medical  man,  and  was  distinctly  limited  to  the  two  ovaries, 
as  was  readily  determined  by  an  examination  under  an  anses- 
thetic.  An  abscess  formed  in  the  right  ovary,  and  I  tapped  it  in 
the  early  stage  by  means  of  the  aspirator,  with  a  completely 
successful  result.  The  general  symptoms  were  pain,  elevation 
of  the  temperature,  night-sweats,  drawing  up  of  the  knees,  infra- 
mammary  pain,  and  pain  shooting  down  the  thighs  and  legs. 
The  chief  remedies  employed  were  counter-irritants,  such  as 
turpentine  stupes  and  blisters,  and  the  internal  administration 
of  quinine  and  opium.  The  aspiration  was,  of  course,  performed 
through  the  vagina. 

Of  this  disease.  Dr.  Mathews   Duncan   describes  a  case  in 


100  DISEASES    OF   THE   OVAKIES. 

which  "the  right  ovary  was  swollen,  renitent,  as  big  as  a  wal- 
nut, and  when  cut  into  was  found  to  have  its  healthy  tissue 
everywhere  utterly  destroyed,  and  converted  into  a  yellow,  puru- 
lent, almost  diffluent  mass.  There  was  no  lymph  in  Douglas' 
space.  Bladder  and  uterus  normal ;  no  general  peritonitis.  Of 
such  ovaritis,  with  suppuration,  examples  are  not  rare,  because 
puerperal  pysemia  is  not  rare,'' 

It  has  long  been  known  that,  in  certain  zymotic  diseases,^ 
especially  in  mumps  and  scarlet  fever,  male  children  are  apt  to 
suffer  from  orchitis,  and  I  remember  seeing  a  statement  some- 
where that  such  inflammation  of  the  testicle  was  likely  to  be  fol- 
lowed by  atrophy  and  loss  of  its  function.  I  cannot,  however, 
verify  my  recollection  by  producing  the  reference. 

In  1870  and  1871,  and  still  more  in  1874,  my  attention  was 
drawn  to  the  occurrence  of  acute  pelvic  peritonitis  in  women 
after  attacks  of  scarlet  fever  and  small-pox,  these  attacks  leav- 
ing indications  which  showed  clearly  that  the  mischief  began  in 
the  ovaries.  Accident  enabled  me  to  trace  the  subsequent  his- 
tory of  two  such  cases,  and  I  found  that  in  both  the  menstruation 
became  greatly  diminished  in  amount,  that  it  was  accompanied 
by  severe  dysmenorrhoeal  symptoms,  and  that  in  one  of  the  cases 
it  entirely  disappeared.  From  these  cases  I  began  to  suspect 
that  the  attacks  were  primarily  due  to  inflammation  of  the 
uterine  appendages,  and  that  this  had  some  kind  of  relation  to 
the  zymotic  diseases  which  preceded  it. 

The  terrible  outbreak  of  small-pox  from  which  this  town  suf- 
fered between  1872  and  1874  gave  me  the  opportunity  of  follow, 
ing  out  this  line  of  research,  and  in  the  second  edition  of  my 
Hastings  Essay  on  the  "  Pathology  and  Treatment  of  Diseases 
of  the  Ovary ''  I  sum  up  my  conclusions  upon  this  subject,  and, 
up  to  the  present  time,  I  have  seen  no  reason  to  modify  them  : 

"  The  occurrence  of  acute  ovaritis  in  certain  of  the  exanthe- 
mata, or  as  a  sequela  to  them,  has  never  yet,  so  far  as  I  know, 
been  placed  in  sufflcient  prominence.  I  have  already  alluded  to 
it,  but  I  wish  here  to  record  further  experience  gained  from  an 
epidemic  of  small-pox  of  considerable  severity,  which  existed  in 
Birmingham  from  1872  to  1874.  Though  practising  exclusively 
as  a  gynecologist,  it  is  somewliat  curious  that  I  was  called  in 
consultation  to  four  cases  as  instances  of  pelvic  ailment  which 
ultimately  proved  to  be  cases  of  small-pox.  One  of  these  gave 
the  clinical  features  of  the  exantliematic  ovaritis  with  great 
clearness.  She  had  been  married  four  years,  and  had  been  con- 
fined twice.  She  was  pregnant  for  the  third  time  in  September, 
1873,  when  she  was  seized  with  a  sudden  rigor,  followed  by  se- 
vere pyrexial  symptoms.     These  rapidly  became  localized  in  the 


OOPHOKITIS   AND   PEKI-OOPHORITIS — ABSCESS   OF   OVARY.    101 

pelvis,  the  patient  complaining  of  excruciating  pain  in  each  iliac 
fossa.  I  saw  her  on  the  fourth  day  of  her  illness,  and  found  her 
suffering  from  double  acute  ovaritis  and  threatening  abortion. 
She  aborted  on  the  fifth  day,  and  then  showed  a  papular  erup- 
tion of  small-pox,  which  rapidly  became  confluent.  She  made  a 
very  protracted  recovery,  and  has  never  menstruated  since. 
The  fundus  uteri  is  fixed  down  on  the  sacrum,  and  both  ovaries 
are  enlarged  and  tender,  the  left  being  firmly  fixed  alongside 
the  uterus. 

*'  In  hospital  practice  I  met  with  a  large  number  of  cases,  of 
which  the  following  is  a  good  example  :  H.  A ,  aged  twenty- 
two,  began  to  menstruate  a  short  time  after  she  was  fourteen, 
and  was  quite  regular  till  August,  1872.  At  that  time  she  had 
an  attack  of  small-pox,  which  she  says  was  not  severe,  and  which 
has  not  left  any  deep  marks.  Up  till  the  time  of  that  illness  she 
was  strong  and  robust,  and  never  knew  what  illness  was.  Dur- 
ing the  attack  she  had  a  very  profuse  menstruation  at  an  irregu- 
lar time,  and  this  was  followed  by  severe  abdominal  pain,  which 
was  treated  by  hot  fomentations.  She  did  not  get  rid  of  this 
pain  entirely  for  some  months,  and  since  then  she  has  menstru- 
ated at  long  intervals,  the  discharge  being  very  scant,  and  ac- 
companied with  great  pain.  She  is  now  very  ansemic,  though 
still  stout,  is  short  of  breath,  and  has  a  loud  systolic  hsemic  mur- 
mur at  the  base.  The  ovaries  are  not  to  be  felt  at  all,  and  there- 
fore it  is  probable  that  they  have  become  atrophied.  She  ob- 
tained considerable  relief  from  small  doses  of  iron,  combined 
with  chlorate  of  potash.  I  have  no  doubt  that  she  had  an  attack 
of  acute  exanthematic  ovaritis,  which  has  led  to  atrophy  of  the 
organs. 

••I  have  repeatedly  seen,  on  post-mortem  examination,  cir- 
rhotic atrophy  of  the  ovaries  in  women  who  had  by  no  means 
reached  the  usual  climacteric  period  of  life,  but  had  prematurely 
ceased  to  menstruate.  In  one  case  only  could  I  get  a  history  of 
the  menstrual  life  of  a  patient,  which  was  to  the  effect  that  she 
had  not  begun  to  menstruate  till  twenty  years  of  age,  and  had 
ceased  before  she  was  thirty  ;  and  about  that  time  she  had  an 
illness  which  probably  was  scarlet  fever.  The  ovaries  were  small 
and  shrivelled,  a,nd  a  stained  section  showed  that  nucleated  and 
banded  fibres  constituted  the  bulk  of  the  glands.  Here  and  there, 
in  small  loculi  whence  the  bands  seemed  to  radiate,  a  small  group 
of  cells  served  to  indicate  the  site  of  a  Graafian  follicle,  but  no 
perfect  follicles  could  be  found.  This  extreme  instance  was  the 
result  probably  of  two  factors — insufficient  development  and  ex- 
anthematic atrophy.  I  think  that  in  such  cases  it  is  likely  that 
future  observation  will  establish  the  existence  of  an    intersti- 


102  dis:eases  of  the  ovaries. 

tial  oophoritis,  distinct  in  character  and  perhaps  in  origin  from 
the  ordinar}^  acute  infianimation  of  the  peritoneal  covering  of 
the  ovary,  to  which  latter  we  might  more  appropriately  give  the 
name  of  peri-oophoritis.  The  results  in  the  two  classes  seem 
to  be  different ;  for  in  the  second,  menstruation  does  not  seem  to 
be  suppressed,  but,  on  the  contrary,  it  is  sometimes  excessive  ; 
while,  as  a  result  of  the  supposed  interstitial  form,  we  have  ova- 
rian atrophy  and  amenorrhcea  of  an  incurable  form  ;  and  when 
it  occurs  in  puerperal  women,  superinvolution  of  the  uterus." 

The  views  which  I  have  expressed  in  these  sentences  have 
now  been  fully  confirmed  by  my  own  experience  and  further  in- 
vestigations, and  I  have  no  doubt  now  that  there  is  a  special 
form  of  oophoritis  associated  with  certain  exanthemata,  more 
particularly  scarlet  fever  and  small-pox,  and  that  in  its  results- 
it  differs  altogether  from  the  form  of  ovarian  inflammation  to 
which  I  prefer  to  give  the  name  of  peri-oophoritis. 

The  most  important  result  of  this  specific  form  of  ovarian  in- 
flammation is  that  it  leads  to  a  cirrhosis  of  the  ovary  which  may 
or  may  not  be  characterized  by  general  atrophy.  It  always  is- 
indicated,  as  I  have  said,  by  atrophy  of  the  true  gland-structure 
and  excess  of  the  fibrous  element.  How  this  may  be  brought 
about  is  not  yet  clear ;  but,  as  I  shall  show  you  immediately, 
the  facts  are  fully  established,  and  my  own  explanation  is  that 
it  is  due  to  the  absorption  of  the  gland-elements  after  the  inflam- 
mation, while  the  fibrous  elements  are  left,  just  as  is  said  to  oc- 
cur in  the  contracted  kidney  and  in  other  instances  of  cirrhosis. ' 

Whatever  be  the  process,  there  is  no  doubt  that  it  is  some- 
times associated  with  atrophy  of  the  uterus,  resulting  in  wbat  is 
known,  and  was  first  described  by  Simpson,  as  superinvolution 
of  the  uterus.  At  page  119  of  my  book  on  "Diseases  of  Women," 
I  hazard  the  following  explanation  of  this  condition  : 

"Of  superinvolution  of  the  uterus,  it  must  first  be  said  that 
it  is  an  extremely  rare  affection,  and  that  all  we  know  about  it 
is  due  to  Simpson.  It  is  a  condition  perfectly  analogous  in  its 
details  to  arrest  of  development  of  the  uterus,  with  the  differ- 
ence in  history  that  the  superinvolved  uterus  has  at  one  time 
been  so  large  as  to  be  pregnant.     How  the  normal  involution  is- 

'  Dr.  Saundby,  Pathologist  to  the  Hospital  for  Women,  who  has  given  much  care 
and  personal  work  to  this  subject,  tells  me  that  it  is  still  a  qiifstio  rcrata  of  pathology 
how  far  the  connective  tissue  of  cirrhosod  organs  is  derived  from  retrogressive  trans- 
formation of  the  pre-existent  more  highly  organized  elements,  e.g.,  glandular  epithe- 
lium, etc.,  into  sj)indle-cells  and  fibres,  and  how  much  is  due  to  cell-migration  from 
the  blood-vessels  and  proliferation  of  the  connective-tissue  corpuscles.  It  is  prob;)ble 
that  the  first  of  those  processes  plays  a  more  important  jiart  tlmn  has  been  assigned  to 
it  in  the  doctrines  which  have  found  most  favor  during  the  past  few  years. 


OOPHORITIS    AND    I'EUI-OOI'HOKITIS — AHSCESS    OF    OVARY.    108 

carried  on  to  hyperercliesis  we  do  not  know ;  and,  so  far  as  I  can 
discover,  we  have  only  one  description  of  the  post-mortem  ap- 
pearance of  a  uterus  so  affected — that  given  originally  by  Simp- 
son. The  patient  was  twenty  years  of  age,  and  had  never  men- 
struated after  her  first  delivery ;  but  no  history  is  given  of  any 
febrile  illness  to  which  might  have  been  attributed  the  abnormal 
absorption  of  the  uterine  substance.  After  death  the  uterus  was 
only  an  inch  and  a  half  long,  and  its  walls  were  less  than  half 
their  normal  thickness,  their  tissue  appearing  dense  and  fibrous. 
The  ovaries  were  also  much  atrophied,  and  their  dense  fibrous 
tissue  presented  no  appearance  of  Graafian  vesicles.  In  this 
case  it  is,  of  course,  doubtful  whether  the  process  was  truly  one 
of  ovarian  atrophy,  followed  by  atrophy  of  the  uterus,  in  obedi- 
ence to  the  usual  law  that  all  useless  organs  tend  to  disappear. 
Several  cases  of  what  I  have  had  reason  to  believe  was  true  su- 
perinvolution  of  the  uterus  have  come  under  my  care,  but  in 
every  one  there  has  been  some  febrile  illness,  generally  of  a 
zymotic  character,  which  occurred  at,  or  soon  after,  a  labor  or 
miscarriage  :  and  my  impression  is  that,  of  all  the  cases,  those 
in  which  a  miscarriage  was  the  origin  of  the  trouble  were  in  the 
majority.  In  fact,  I  am  strongly  disposed  to  regard  superinvolu- 
tion  as  a  result  of  an  atrophic  inflammation  occurring  at  the  time 
when  involution  is  going  on.  Thus,  in  a  case  which  I  published 
in  the  London  Obstetrical  Journal  for  May,  1873,  and  which  cer- 
tainly was  the  most  pronounced  case  of  superinvolution  I  have 
ever  seen,  the  patient  had  had  scarlet  fever  during  the  first  week 
of  her  convalescence  from  her  second  labor.  She  came  under 
my  care  in  1871,  seven  years  after  the  fever,  and  has  remained 
under  observation  ever  since.  When  I  first  saw  her  the  uterus 
was  perfectly  infantile,  the  vaginal  portion  of  the  cervix  being 
represented  only  by  a  pimple.  Her  menstrual  periods  had  dis- 
appeared, and  were  replaced  by  severe  epileptiform  seizures,  as 
will  be  found  detailed  in  the  journal.  I  succeeded  in  getting 
menstruation  restored,  and  the  uterus  increased  in  size  by  the 
use  of  galvanic  pessaries,  and  as  her  periods  became  re-estab- 
lished the  epilepsy  disappeared.  But  when  I  discontinued  the 
use  of  the  pessary  the  menstruation  slowly  disappeared  and  the 
fits  came  gradually  back,  and  this  therapeutical  experiment  has 
been  sevei-al  times  repeated  with  uniform  results  ;  and  that  the 
fits  are  epileptic  is  made  certain  by  the  severe  injuries  the  poor 
woman  inflicts  upon  herself  during  the  attacks.  Looking  back 
on  this  case  and  others,  and  aided  by  the  evidence  of  other  facts 
referred  to  under  the  head  of  exanthematic  ovaritis,  I  am  led  to 
believe  that  superinvolution  is  explained  by  the  occurrence  of  in- 
flammation, followed  by  atrophy,  during  the  puerperal  month  ; 


104  DISEASES    OF   THE    OVARIES. 

and  that  the  uterus  merely  follows  in  the  steps  of  the  ovary,  car- 
rying the  process  farther,  however,  because  it  had  been  already 
in  action,  and  stopping  it  only  when,  perhaps,  there  was  no  more 
muscular  tissue  left  to  absorb. '  I  do  not  suppose  that  the  excit- 
ing ovaritis  need  necessarily  be  exanthematic,  but  peri-oophoritis, 
or  inflammatory  action  affecting  only  the  covering  of  the  ovary, 
does  not  seem  to  affect  menstruation;  it  rather  inclines  to  induce 
sterility  only.  These  views  would  explain  many  facts  w^iich  are 
otherwise  irreconcilable,  and,  what  is  most  of  all  remarkable, 
the  rarity  of  superinvolution.  First  of  all.  exanthematic  or  other 
interstitial  ovaritis,  such  as  leads  to  ovarian  atrophy  and  is  not 
fatal,  is  very  rare  in  puerperal  women,  the  great  majority  of 
such  cases  ending  in  death.  The  few  w^lio  recover  are  likely  to 
suffer  from  superinvolution.  Again,  numbers  of  non-puerperal 
women  who  suffer  from  ovarian  atrophy,  the  result  of  inflam- 
mation, do  not  at  the  same  time  have  atrophy  of  the  uterus, 
because  when  the  ovarian  process  began  the  uterus  was  not  al- 
ready undergoing  involution.  This  explanation  is  quite  in  ac- 
cordance with  the  history  of.  and  the  appearances  in,  Simpson's 
case,  and  also  in  harmony  wath  the  general  principles  of  uterine 
physiology.  Its  practical  bearing  is,  that  though  in  such  cases 
we  may  get  temporary  relief  from  the  galvanic  stem,  that  relief 
will  cease  with  the  use  of  the  instrument,  or  when,  as  sometimes 
happens,  its  stimulus  becomes  insufficient." 

The  case  now  referred  to  is  one  of  so  much  importance  that, 
at  the  risk  of  being  tedious,  I  shall  give  its  history  fully  from  my 
first  acquaintance  with  the  patient.  The  former  part  of  the  case 
I  take  from  the  Obstetrical  Journal  of  May,  1873. 

"  E  E ,  aged  thirty-five,  came  under  my  care  in  November, 

1871,  at  the  hospital.  She  had  been  married  twelve  years,  and 
had  two  children,  the  last  of  which  Avas  born  seven  years  ago. 
She  had  scarlet  fever  after  this  labor,  and  the  menses  were  long 
in  reappearing.  When  they  did  come  they  were  scanty  and  very 
painful,  and  occurred  irregularly  at  intervals  of  from  five  weeks 
to  three  months,  lasting  only  one  day,  or  two  at  most.  About 
four  years  previous  to  her  first  visit,  slight  attacks  of  an  epilepti- 
form nature  occurred  at  each  period— almost  imperceptible  at 
first,  but  getting  gradually  worse  as  the  periods  got  more  irregu- 


'  It  is  not  to  be  supposed  for  :i  moment,  however,  that  the  uterus  ever  can  be  so 
absorbed  as  to  disappear  altogether,  even  though  it  may  be  so  thin  that  a  sound  can 
be  passed  through  it,  as  in  tlie  case  recorded  iu  the  British  Medical  Journal  for  1873, 
]).  4()S.  by  Mr.  Whitehead,  of  Manchester.  At  p.  4(!r)  of  the  same  volume  I  offered  the 
moie  feasible  explanation  that  there  had  been  formed  a  metro-peritoneal  fistula. 


OOPIIOIIITIS   AND   PP:KI-00PH0KITIS — ABSCESS   OF   OVARY.    105 

lar  and  scantier.  For  some  months  previous  to  applying  at  the 
hospital  she  had  two  or  three  severe  fits  at  each  period,  each  fit 
leaving  her  insensible  for  some  hours,  and  often  with  severe  in- 
juries. On  November  oth  she  had  had  a  period  and  a  very  severe 
fit ;  Oth,  ordered  five-grain  doses  of  the  bromide  of  potassium 
thrice  daily,  and  an  aloes  and  iron  pill  twice  a  week.  Examined 
on  the  IGtli,  and  the  uterus  found  quite  infantile  ;  ovaries  normal. 
The  uterus  was  so  small  that  I  failed  to  get  anything  into  its 
cavity.  On  the  30th  I  doubled  the  dose  of  the  bromide.  Decem- 
ber 7th,  menstruated  for  one  day,  and  had  increased  flux  and  no 
fit.  Menstruated  January  4th  and  5th,  with  slightly  increased 
amount,  and  one  severe  fit  on  second  day.  Had  a  severe  fit  on 
22d,  without  any  menstrual  flow — the  first  time  this  has  hap- 
pened. Menstruated  February  1st  and  2d  ;  no  fit.  March  11th 
and  12th,  menstruation  without  fit,  but  a  severe  seizure  occurred 
almost  immediately  after  the  fiux  ceased.  On  the  18th  Mr.  Jor- 
dan kindly  put  her  under  chloroform  for  me,  and  I  got  a  small 
tangle-tent  into  the  uterus.  I  at  the  same  time  discovered  that 
there  was  considerable  anteflexion,  March  25th,  passed  in  No.  8 
tangle-tent,  and  on  the  29th  I  got  No.  8  galvanic  stem  in.  April 
5th,  got  in  No.  12  stem  ;  7th,  8th,  and  Oth,  menstruated  more  pro- 
fusely than  she  has  done  for  years,  and  without  a  fit,  though 
one  occurred  on  the  16th.  She  still  wears  the  stem,  and  men- 
struates regularly  and  profusely,  but  has  no  fits." 

From  this  point  I  continue  the  case  from  the  hospital  record. 

On  April  2Gth,  1873,  I  introduced  No.  16  galvanic  stem,  the 
largest  I  have  ever  used,  and  from  May  3d  to  7th  she  had  a  pe- 
riod more  profuse  than  she  had  ever  had  since  her  confinement. 
On  June  4th  she  again  menstruated  for  four  days,  again  in  July, 
and  also  in  August  and  September,  during  which  time  she  wore 
the  large  stem,  and  had  not  a  single  fit. 

The  stem  was  removed  at  the  end  of  September,  having  been 
worn  five  months  with  most  satisfactory  results.  In  November 
she  menstruated  for  one  day  only,  and  in  December  there  was 
no  appearance  of  it  at  all,  but  a  fit  occurred  at  the  time  it  was 
expected.  During  the  whole  of  this  time  she  was  taking  sixty 
grains  of  the  bromide  each  day.  The  fits  recurred  at  each  period 
when  menstruation  ought  to  have  appeared,  so  that  on  May  16th 
I  had  recourse  again  to  the  galvanic  stem.  She  menstruated 
from  the  20th  to  the  24th  without  any  fit,  and  she  wore  the  stem 
with  only  very  occasional  fits,  and  with  perfect  and  regular  re- 
currency  of  menstruation,  till  November,  when  the  stem  was 
removed.  By  the  following  March,  1874,  the  fits  had  reappeared, 
and  the  menstruation  was  again  in  abeyance,  and  just  as  it  dis- 
appeared the  fits  were  re-established. 


106  DISEASES   OF   THE   OVAKIES. 

During  1875  I  saw  her  only  occasionally,  as  it  was  only 
when  she  was  worse  than  usual  that  she  came  for  the  bromide 
mixture.  It  was  quite  clear  then  that  her  mental  qualities  were 
becoming  dulled,  and  she  was  rapidly  taking  on  the  character- 
istic face  of  an  epileptic  imbecile.  During  1876  another  effort  to 
re-establish  the  periods  by  means  of  the  galvanic  stems  was 
made,  but  with  results  less  satisfactory  than  those  made  in  pre- 
vious years.  On  February  5,  1.877,  I  was  asked  to  see  her  at  her 
own  house,  and  found  her  in  a  condition  of  epileptic  mania. 
I  advised  her  removal  to  an  asylum,  but  her  husband  and  mother 
declined  to  act  upon  my  suggestion,  despite  its  being  quite  evi- 
dent to  them  that  the  injuries  she  injflicted  upon  herself  during 
the  fits  were  of  so  serious  a  character  as  to  endanger  her  life, 
and  from  her  occasional  violence  during  the  delirium  it  was 
quite  possible  she  might  become  a  homicide.  Every  month 
the  fits  returned  with  increasing  severity,  and  the  attacks  of 
mania  fastened  themselves  almost  wholly  upon  the  week,  dur- 
ing which  a  slight  loss,  lasting  for  a  few  hours,  indicated  that 
her  menstruation  should  have  occurred  then.  The  bromide  of 
potash  was  pushed  to  as  much  as  two  hundred  grains  a  day 
without  the  slightest  effect,  and  other  drugs  were  tried  equally 
without  avail. 

In  July.  1879,  lier  condition  was  so  dreadful  that  her  friends 
at  last  determined  to  send  her  to  an  asylum,  and  I  saw  her  on 
the  28th.  She  was  almost  completely  fatuous,  her  memory  was 
almost  gone,  the  fits  seemed  to  miss  only  one  week  in  four,  the 
attacks  of  mania  were  irregular  and  continued  for  varying  pe- 
riods, and  menstruation  occurred  at  irregular  times.  Yet,  on  the 
whole,  it  was  said  by  her  mother  that  she  was  at  her  worst  very 
regularly  one  week  out  of  the  four. 

It  occurred  to  me  that,  if  my  view  were  correct,  that  this  was 
a  case  of  menstrual  epilepsy  really  depending  upon  exanthe- 
matic  cirrhosis  of  the  ovary,  removal  of  tlie  ovaries — an  operation 
of  very  ancient  date,  and  which  I  performed  for  the  first  time  in 
this  country  in  1872 — held  out  some  prospect  of  curing  this  un- 
happy woman.  At  least  it  could  not  make  her  worse  than  she 
was,  for,  even  if  she  died  under  it,  the  release  would  be  a  grateful 
one  to  all  concerned.  Her  relatives,  therefore,  gave  a  ready  con- 
sent to  my  proposal  when  I  laid  it,  and  the  reasoning  upon  which 
I  based  it,  before  them. 

I  therefore  admitted  the  patient  to  the  Women's  Hospital, 
and,  with  the  concurrence  of  my  colleagues,  I  removed  the  ova- 
ries on  August  11th. 

This  operation — according  to  my  ex])erience  one  of  the  most 
successful  operations  in  surgery,  and  likely  to  prove  of  infinite 


OOPHOIilTIS   AND   PEKI-OOPIIOltlTIS — ABSCESS   OF   OVARY.    107 

service  to  suffering  women — was  first  performed  in  1872  by  Pro- 
fessor Hegar,  of  Leipsic,  and  he  first  published  his  proposal. 
Within  a  very  few  days  after  Professor  Hegar's  operation  it  was 
performed  here  by  myself,  some  months  before  Professor  Hegar's 
account  of  his  case  reached  this  country.  Dr.  Battey,  whose 
name  it  is  proposed  to  fix  upon  this  operation,  did  not  operate 
till  after  Hegar  and  myself,  and  his  publication  was  also  subse- 
quent to  both  of  ours. 

The  operation  in  the  case  of  E.  E was  made  somewhat 

difficult  by  her  being  extremely  fat.  A  somewhat  profuse  cata- 
menial  flow  set  in  on  the  third  day  after  the  operation,  and  lasted 
for  three  days,  but  without  the  slightest  appearance  of  a  fit. 
This  pseudo-menstruation  is  very  common  after  ovarian  opera- 
tions, and  often  recurs  for  two  or  three  months  after  removal  of 
both  ovaries. 

The  stitches  were  removed  on  the  ISth,  and  she  sat  up  on  the 
23d  of  August,  twelve  days  after  the  operation. 

I  went  away  for  my  holiday,  and  did  not  return  till  the  29th 
of  September,  when  I  found  her  an  altogether  different  woman. 
She  had  had  no  fits,  no  more  menstruation,  was  bright  and  cheer- 


Fig.  24. — Exanthematic  cirrhosis  of  ovary. 


f ul  in  her  face,  her  memory  returning,  and  she  had  altogether 
lost  the  dull,  heavy,  epileptic  look  which  she  had  before. 

I  last  saw  her  on  October  loth,  when  she  was  about  to  go  to 
her  home  in  Peterborough,  and  she  and  her  friends  were  satisfied 
as  to  her  perfect  recovery,  and  were  as  grateful  as  people  could 
be  for  the  improvement  in  the  patient's  condition. 

One  question  of  course  remains  :  Will  the  improvement  be 
permanent  ?  I  do  not  know.  It  seems  almost  too  much  to  hope 
for,  but  I  really  think  it  will  be.  The  description  of  the  ovaries 
by  my  friend,  Mr.  Alban  Doran,  completely  justifies  my  view  of 
the  pathology  of  the  case,  and  my  treatment  is  but  a  logical  con- 


108 


DISEASES   OF   THE   OVARIES. 


elusion  from  that  view.  After  such  an  operation  one  would 
expect  that  the  fits  would  probably  continue  for  a  few  months, 
and  gradually  disappear.  But  here  they  have  disappeared  at  a 
blow,  and,  after  nearly  three  months'  absence,  I  think  they  may 
be  expected  to  have  finally  disappeared. 

The  ovaries  removed  were  not  much  smaller  than  normal 
ovaries,  but  they  were  fissured  in  a  most  remarkable  manner,  so 
as  to  resemble  in  miniature  the  kidneys  of  an  ox,  or  the  convolu- 
tions of  the  human  brain.  I  sent  one  up  to  the  College  of  Sur- 
geons' Museum,  and  I  quote  from  Mr.  Doran's  report  upon  it,  as 
follows  : 

"  There  are  no  signs  of  'alveolar  degeneration,'  but  the  elon- 
gated cells  of  the  stroma  are  larger  than  in  normal  ovaries,  and 


Fig.  25  (drawn  by  Mr.  Alban  Doraii). — Mieroscopio  aiippaniiici's  of  cirrhotic  ovary,  mapnified  diame- 
ters :  a,  Normal  arteriole ;  6,  Binall  vessel  occluded  ;  c,  c,  debris,  probably  site  of  vesseLs  occluded  by  pres- 
Bure  of  new  cellular  tissue. 

there  are  few  vessels;  the  hypertrophy  of  those  that  remain,  and 
the  bundles  of  fibrous  tissue,  point  to  a  cirrhotic  change  follow- 
ing the  exanthematic  oophoritis.  There  were  no  morbid  C3'sts, 
nor  extravasation  of  blood  ;  no  pathological  breaking  down. 
There  were  two  Graafian  vesicles,  each  about  one-twentieth  of 
an  inch  in  diameter,  l)()th  close  to  the  surface,  the  periphery  of 
the  ovary  being  slightly  denser  than  the  deeper  stroma,  to  the 
depth  of  one-eighth  of  an  inch.  Near  the  inner  extremity  of  the 
ovary  is  a  menstrual  corpus  luteum  which  makes  a  distinct  bulge 
on  the  surface." 


OOPHOEITIS   AND   PERI- OOPHORITIS — ABSCESS   OF   OVARY.    10& 

I  cannot  conclude  the  notes  of  this  case  without  restating  my 
belief  that,  in  this  operation  for  the  removal  of  the  uterine  ap- 
pendages, we  have  the  means  of  alleviating  an  enormous  amount 
of  suffering  of  an  otherwise  incurable  kind. 

The  conclusions  which  I  have  made  concerning  the  influences 
of  exanthematic  diseases  upon  the  ovaries  have  already  been 
confirmed  by  many  interesting  observations,  chiefly  by  Dr.  Lebe- 
dinsky.  In  the  specimens  he  has  examined  during  the  actual 
process  of  inflammation,  he  describes  the  macroscopic  appear- 
ances as  unchanged  both  on  the  surface  and  in  section.  He  ex- 
amined the  ovaries  after  having  hardened  them  in  Miiller's 
fluid  and  afterward  in  alcohol  and  picric  acid.  He  found,  on 
section,  that  all  the  Graafian  follicles  were  in  a  condition  of  pa- 
renchymatous inflammation,  which  commenced  in  turbid  swell- 
ing of  the  epithelium,  and  proceeded  to  the  complete  destruction 
of  the  cells.  The  ovarial  stroma  was  not  affected  beyond  being 
hypersemic  in  the  neighborhood  of  some  of  the  follicles.  He 
found  the  destruction  of  the  glandular  tissue  most  marked  in  the 
case  of  a  girl  eight  years  of  age,  who,  during  her  convalescence 
from  scarlet  fever,  was  attacked  by  measles,  of  which  she  died 
on  the  eighth  day.  The  great  majority  of  the  follicles  in  the 
ovaries  of  this  patient  were  occupied  by  a  finely  granular,  struc- 
tureless material,  and  in  the  cortical  layer  the  follicles  seem  to 
have  been  almost  entirely  destroyed.  Lebedinsky  regards  this 
affection  of  the  ovaries  as  being  quite  analogous  to  the  well- 
known  parenchymatous  inflammations  of  other  organs  during 
the  progress  of  infectious  diseases.  The  result  is  a  destruction 
of  a  larger  or  smaller  number  of  follicles,  and  the  consequent  in- 
terference with  the  subsequent  function  of  the  ovaries  in  corre- 
sponding degree,  so  that  the  fecundity  of  the  infected  person 
will,  in  severe  cases,  be  rendered  extremely  problematical,  and 
this  will  be  a  certain  result  if  the  tubes  are  also  found  to  have 
been  damaged.  This  is  the  case  in  by  far  the  larger  number  of 
cases,  and  the  tubes  share  in  the  general  atrophy  of  the  parts  in 
the  subsequent  cirrhotic  change. 

As  I  have  already  indicated,  chronic  ovaritis  may  be  a  later 
stage  of  moliminal  hypersemia.  It  may  also  be  the  result  of 
acute  ovaritis  ;  but  the  majority  of  the  cases  occur  from  sexual 
excess  and  masturbation,  or  as  a  sequela  of  exanthemata  and 
rheumatic  fever,  and  probably  of  syphilis.  I  have  only  once  had 
an  opportunity  of  dissecting  a  case  where  I  had  recognized 
chronic  ovaritis  in  life,  and  then  it  certainly  was  the  result  of 
acute  rheumatism.  It  occurred  in  the  case  of  a  girl  seventeen 
years  old,  who  had  suffered  from  eight  or  nine  attacks  of  rheu- 
matic fever.    In  two  of  them  she  was  under  my  care  as  a  dispen- 


110  DISEASES   OF  THE   OVARIES. 

sary  patient :  and  after  the  recession  of  the  articular  affection 
an  attack  of  pelvic  pain  came  on,  which  was  increased  by  pres- 
sure, and  the  attack  was  accompanied  by  an  irregular  menstrual 
flow.  The  whole  passed  off  in  a  few  days  after  the  application 
of  a  blister,  but  ever  afterward  her  menstruation  was  irregular, 
profuse,  and  painful,  and  she  suffered  more  or  less  from  the 
symptoms  I  shall  describe  immediately.  I  regarded  the  attack 
as  one  of  mild  acute  or  subacute  ovaritis,  followed  by  a  chronic 
stage.  She  died  subsequently  of  embolism  of  a  cerebral  artery, 
and  I  found  her  ovaries  large,  soft,  covered  with  lymph,  and 
dotted  with  enlarged  follicles,  and  the  peritoneum  was  thickened 
around  them.  The  left  ovary  was  partly  adherent  to  the  rectum, 
and  it  had  nearly  the  whole  of  the  fimbriae  of  the  corresponding 
tube  glued  on  to  it. 

The  following  case  illustrates  the  same  lesion  in  a  more 
chronic  stage  of  its  progress  : 

H.  B .  aged  thirty,  was  placed  under  my  care  in  Septem- 
ber by  Dr,  Bradley,  of  Dudley,  who  told  me  that  when  she  came 
under  his  care  she  had  retroflexion  and  a  variety  of  somewhat 
severe  symptoms,  including  pains  in  the  groins,  extending  down 
both  thighs  and  into  the  back,  which  were  much  worse  just  be- 
fore the  menstrual  period.  He  remedied  the  retroflexion  by  one 
of  Graily  Hewitt's  pessaries,  but  the  pains  still  continued  as  bad 
as  before,  and  he  sent  her  to  me  with  a  letter  containing  this 
sentence  :  "  It  seems  to  me  that,  in  order  to  completely  cure  her, 
it  might  be  necessary  to  remove  one  or  both  ovaries." 

The  history  that  she  gave  was  as  follows  :  Her  menstruation 
began  at  the  age  of  fourteen,  and  was  at  first  regular  and  nor- 
mal. At  the  age  of  eighteen,  while  resident  in  Paris,  she  had 
an  attack  of  rheumatic  pleuro-pneumonia,  and  after  that  she  did 
not  menstruate  for  seven  months.  It  is  not  quite  clear,  but  I 
think  it  more  than  likely  that  at  this  time  she  had  an  attack  of 
ovaritis,  because,  during  her  convalescence,  she  found  that  she 
could  not  for  many  months  straigliten  herself  on  account  of  se- 
vere pelvic  pains,  which  existed  on  both  sides,  and  extended 
down  the  thighs,  and  which  prevented  her  walking  any  distance 
for  a  long  time.  At  the  end  of  the  seven  months  she  got  some- 
what better,  and  her  periods  returned,  but  she  suffered  intense 
pain  while  they  were  on.  Three  years  before  I  saw  her,  while 
resident  in  Poland,  she  had  a  severe  attack  of  pelvic  inflamma- 
tion, which  was  at  the  time  regarded  as  being  of  a  rheumatic 
character.  Since  that  attack  her  menstruation  has  always  been 
extremely  irregular  and  very  painful,  so  that  practically  for  three 
weeks  in  every  month  she  has  been  wholly  unable  to  do  any- 


OOPIIUKITIS   AND    PKKI-OOPIIOKITIS — ABSCESS    OF    OVARY.    Ill 

thing,  or  even  to  walk,  and  for  two  years  previous  to  my  seeing 
her  she  had  not  been  able  to  follow  her  occupation  of  a  governess. 
I  found  the  uterus  fairly  normal  in  position,  and  down  behind 
it  and  on  either  side  the  ovaries  could  be  felt,  large  and  nodular, 
just  like  mulberries.  They  were  extremely  tender  and  evidently 
adherent.  After  some  further  discussion  with  Dr.  Bradley,  it 
was  determined  to  remove  the  organs,  and  this  operation  I  per- 
formed on  October  2G,  ISbU,  I  found  the  ovaries  adherent,  nodu- 
lated, studded  with  minute  cysts,  and  markedly  cirrhotic  ;  they 
were  very  friable,  and  their  removal  was  a  matter  of  great  diffi- 
culty. With  them  I  removed  the  adherent  tubes.  She  recovered 
rapidly,  but  unfortunately  during  the  process  of  recovery  she 
had  a  haematocele,  and  though  she  has  improved  steadily  since 
the  operation,  her  progress  has  been,  on  account  of  this  accident, 
neither  so  rapid  nor  so  satisfactory  as  I  could  wish,  nor  as  has 
been  the  rule  in  most  of  my  cases.  The  condition  of  her  ovaries 
very  well  illustrates  the  result  of  the  interstitial  form  of  oopho- 
ritis which  is  a  result  of  rheumatic  disease. 

Speaking  of  chronic  ovaritis.  Dr.  Mathews  Duncan  gives  the 
following  valuable  evidence,  which  I  quote  in  full  on  account  of 
the  precision  of  the  language,  the  eminence  of  the  author,  and 
most  of  all  because,  as  Dr.  Mathews  Duncan  does  not  practise 
surgery,  he  may  be  expected  to  give  his  opinions  without  surgi- 
cal bias  : 

"These  cases,  indeed,  generally  resist  all  treatment.     Here 

is  a  case  :  A.  H ,  aged  twenty-four,  married  a  year  and  a  half, 

never  pregnant ;  catamenia  regular.  She  complains  of  painful 
menstruation.  On  examination  the  left  ovary  is  easily  felt,  and 
somewhat  swollen  and  tender.  The  uterus  is  natural,  except 
extreme  sensitiveness  of  the  mucous  membrane  of  its  body.  The 
cervix  permits  easily  the  passage  of  only  a  No.  7  bougie.  After 
some  partially  successful  treatment  of  the  dysmenorrhoea,  she 
left  the  hospital,  but  soon  returned,  saying  she  was  not  cured. 
Now,  she  privately  made  known  that  what  she  wished  cured  was 
not  so  much  her  painful  menstruation  as  pain  in  sexual  connec- 
tion, a  pain  which  delicacy  had  prevented  her  from  earlier  men- 
tioning. With  this  in  view  she  was  re-examined,  and  now  both 
ovaries,  somewhat  prolapsed,  swollen,  and  tender,  yet  freely 
mobile,  were  easily  felt.  Pressure  on  either  of  them  produced 
pain,  which  she  recognized  as  that  of  her  dyspareunia.  She  is 
now  under  treatment.  Counter-irritants  externally,  and  small 
doses  of  corrosive  sublimate  internally,  are  being  used.  I  can 
only  say  I  hope  she  will  be  cured.'' 

Here,  then,  we  are  dealing  with  a  disease  which  one  of  the 


112  DISEASES    OF   THE    OVAKIES. 

greatest  living  gynecologists  frankly  admits  is  almost  incurable. 
In  hospital  practice  I  assert  that  it  is  absolutely  incurable  in  by 
far  the  greater  number  of  cases.  The  only  means  of  arriving  at 
so  satisfactory  a  result  is  limited  to  the  classes  possessing  wealth 
and  education,  for  with  them  alone  is  it  possible  to  secure  the 
obedience  to  directions  and  the  perseverance  in  treatment  by 
which  it  is  possible  occasionally  to  get  a  cure.  More  than  this, 
it  is  only  in  a  life  of  luxury  that  it  is  possible  to  prevent  the  re- 
lapses to  which  this  disease  is  so  liable. 

The  symptoms  of  the  disease  vary  very  considerably,  yet 
there  are  certain  features  common  to  all  the  cases  which  are 
sufficiently  definite  for  reliance  to  be  placed  upon  them  for  pur- 
poses of  diagnosis. 

Pain  is  an  inevitable  feature,  and  nineteen  times  out  of 
twenty  it  is  worse  on  the  left  side  than  on  the  right ;  and  if  it 
exist  on  one  side  only,  it  is  almost  certain  to  be  the  left  which  is 
affected.  The  explanation  which  I  offer  of  this  peculiarity  will 
be  found  in  the  first  chapter  (p.  8). 

This  pain  is  always  referred  to  the  groin  as  the  point  of  origin 
and  of  its  greatest  intensity.  It  is  nearly  always  persistent,  and 
liable  to  exacerbation  when  the  patient  is  in  the  erect  position — 
when  walking,  but  more  particularly  when  being  jolted  in  a  car- 
riage. It  also  becomes  more  intense  as  the  organs  become  con- 
gested at  the  monthly  periods.  When  the  pain  is  intensified 
from  any  cause,  it  extends  from  its  habitual  seat  down  the  thighs 
and  round  into  the  back,  and  very  often  a  reflex  pain  is  excited 
in  the  breast  of  the  same  side.  Sometimes  the  pain  is  so  great 
as  to  i)revent  the  patient  straightening  herself,  and  obliges  her  to 
walk  what  little  she  does  in  a  semi-bent  attitude.  Pressure  upon 
the  seat  of  pain  always  increases  it,  and  the  slightest  touch  on 
the  ovary  from  the  vagina  gives  rise  to  a  peculiar  sickening  sen- 
sation which  is  very  characteristic.  For  this  reason,  and  also 
from  the  fact  that  her  chronically  inflamed  ovary  is  nearly  al- 
ways displaced  downward,  marital  intercourse  is  generally  a 
cause  of  great  pain,  and,  in  the  majority  of  instances,  is  abso- 
lutely unendurable.  Generally  speaking,  the  pain  lasts  through- 
out the  whole  period  of  menstruation  ;  but  in  some  instances  it 
varies  in  this  particular,  for  in  some  of  the  most  pronounced 
cases  of  chronic  ovaritis  that  I  have  seen,  the  pain  ceased,  or  at 
least  was  greatly  diminished,  on  the  appearance  of  the  menstrual 
flow. 

Menstruation  itself  is,  in  most  cases,  profuse,  but  in  some  of 
the  cases  I  have  already  detailed  this  profuse  metrorrhagia  is 
due  not  so  much,  perhaps,  to  the  ovaritis  as  to  the  fundal  metri- 
tis and  the  inflammation  of  the  tubes  with  which  it  was  associ- 


OOPnOKITlS    AND    PEKI-OOPIIOKITIS — ABSOKSS    OF    OVARY.    113 

ated,  and  it  has  been  the  chief  cause  for  interference  by  surgical 
operation.  Those  cases  in  which  hemorrhage  is  a  characteristic 
are,  I  believe,  those  in  which  the  inflammation  is  of  an  intersti- 
tial character,  and  probably  not  of  that  kind  in  which  the  cir- 
rhotic change  subsequently  occurs.  I  have  found  that,  in  the 
cirrhotic  cases,  there  is  less  inflammation  of  the  other  organs, 
and  generally  an  atrophy  of  them,  as  of  the  ovary  itself  in  the 
later  stages  ;  and  that,  as  a  consequence,  the  periods,  instead  of 
being  profuse,  become  rather  scanty.  It  is  in  the  former  cases 
that  we  find  the  ovary  studded  with  small  cysts,  whereas  in  the 
others  the  increase  in  the  size  of  the  ovary  is  of  the  solid  kind. 

But  as  yet  there  is  not,  either  in  my  own  practice  or  in  that 
of  any  others  yet  published,  any  sufficiently  precise  data  upon 
which  an  absolute  conclusion  in  this  matter  may  be  founded ; 
indeed,  it  has  only  been  of  very  recent  time  that  we  have  been 
able  to  see  these  diseased  ovaries  in  cases  where  the  clinical  his- 
tory was  accurately  known.  Our  experience  is  as  yet  insufficient 
to  warrant  us  in  asserting  any  positive  conclusion. 

It  is,  however,  perfectly  certain  that  there  are  two  kinds  of 
pathological  appearances  produced  by  chronic  ovaritis,  and  these 
are  probably  the  result  of  two  wholly  different  morbid  processes. 
It  is  in  the  cases  where  we  have  a  cyst-production  that  we  have 
the  most  adhesions  formed,  and  I  think,  from  what  I  have  al- 
ready seen,  that  it  is  very  likely  that  these  adhesions  are  pro- 
duced by  limited  inflammations  resulting  from  the  rupture  of 
these  small  cysts.  This  phenomenon  was  originally  described 
by  Dr.  Mathews  Duncan,  and  I  have  seen  the  results  of  it,  I  be- 
lieve, in  several  instances,  and,  in  one  of  my  cases,  I  have  twice 
been  quite  certain,  from  the  completely  altered  condition  of  the 
ovary  at  separate  examinations,  that  such  ruptures  must  have 
taken  place,  I  have  so  often  seen  these  cysts  rupture  immedi- 
ately the  ovary  was  touched,  that  I  can  have  no  doubt  of  the  ac- 
curacy of  Dr.  Duncan's  description.  I  exhibited  a  specimen  re- 
cently to  the  Pathological  Society  of  a  cyst  of  the  Fallopian  tube, 
which  I  had  recognized  as  having  repeatedly  been  the  subject  of 
rupture,  each  rupture  being  followed  by  an  attack  of  acute  peri- 
tonitis. The  specimen  was  obtained  on  post-mortem  examina- 
tion, after  the  sudden  death  of  the  patient. 

The  physical  examination  of  a  case  of  this  kind  requires  to  be 
conducted  with  a  great  deal  of  care,  for  nothing  disappoints  a 
suffering  woman  more  than  to  have  her  pain  increased  by  rough 
handling.  When,  therefore,  the  practitioner  hears  a  narration  of 
such  symptoms  as  I.  have  described,  let  him  be  careful  how,  by 
his  finger,  or  the  sound,  or  the  speculum,  he  injures  a  displaced 
and  inflamed  ovary  or  tube.  It  will,  as  I  have  already  said,  be 
•  8 


114  DISEASES    OF   THE    OVARIES. 

easily  found  behind,  and  about  on  a  level  with,  the  upper  part 
of  the  cervix.  A  careless  observer  may  mistake  it  for  a  retro- 
fleeted  fundus,  and  introduce  a  pessary  for  its  replacement  ;  but 
this  will  prove  to  be  nearly  always  a  source  of  disappointment ; 
indeed,  as  I  have  already  said,  it  may  be  a  source  of  danger. 
Besides  the  symptoms  of  inflammation  of  the  ovary  in  a  chronic 
case,  there  are  symptoms  of  uterine  complication,  and  a  very 
great  many  of  the  cases  of  intractable  endometritis  met  with  in 
practice  are  really  but  expressions  of  the  same  serious  disease. 

For  the  treatment  of  this  disease  the  most  important  of  all 
considerations  is  physiological  rest.  For  this  purpose  the  wo- 
man must  regard  herself  as  an  absolute  invalid  during  her  men- 
strual week,  remaining  in  bed  the  whole  of  that  time.  This  con- 
dition at  once  separates  the  hospital  from  the  private  patient, 
and  therefore  we  find  that,  while  in  hospital  practice  it  is  almost 
impossible  to  permanently  cure  a  case  of  chronic  ovaritis,  yet,  in 
many  of  our  cases  in  private  practice,  a  cure  may  be  accom- 
plished by  patience  and  perseverance.  Besides  the  menstrual 
rest,  there  should  be  complete  cessation  of  marital  intercourse. 
If  it  be  found  that  the  ovary  is  displaced  and  not  adherent,  it 
may  be  replaced  by  pessary  or  the  genupectoral  position,  as  al- 
ready described  (in  the  chapter  on  ovarian  displacements).  Over 
the  groin  counter-irritation  should  be  employed  by  means  of  blis- 
ters of  iodine  or  cantharides,  my  favorite  formula  being  a  mix- 
ture of  equal  parts  of  the  tincture  and  liniment  of  iodine  (B.  P.), 
to  be  painted  on  over  the  groin  every  morning,  as  long  as  the 
skin  will  stand  it.  When  it  can  no  longer  be  borne,  the  skin  is 
allowed  to  peel  off  and  become  again  quite  fresh,  and  after  that 
the  processes  are  to  be  repeated  for  some  months.  Of  internal 
remedies,  the  only  drugs  which  I  have  seen  of  the  slightest  ser- 
vice are  bromide  and  chlorate  of  potash,  and  nux  vomica.  These 
I  generally  give  in  combination,  or  alternately,  the  patient  taking 
from  fifteen  to  twenty  grains  of  the  bromide  or  of  the  chlorate 
for  a  month,  and  then  the  nux  vomica  for  a  month. 

In  these  cases  I  never  give  iron  when  there  is  any  tendency 
to  hemorrhage,  or,  indeed,  in  any  other  condition  when  that 
symptom  is  prominent.  I  have  always  found  iron  do  harm  then; 
and  in  support  of  my  views  upon  this  point,  which  have  been 
very  adversely  criticised,  I  cannot  do  better  tlian  quote  Dr.  Alfred 
Meadows  :  "I  do  not  think  I  at  all  exaggerate  when  I  say  that, 
in  ninety-nine  out  of  every  hundred  cases  of  menorrhagia  which 
come  before  the  practitioner  for  treatment,  his  first  thought  is, 
What  form  of  astringent  shall  I  give  ?  And  the  answer  prc^ba- 
bly  i'l  most  oases  will  be,  an  astringent  chalybeate— either  the 
}»erchloride  or  the  T)ernitrato  ;  or  some  similar  preparation  of  iron 


OOPHORITIS    AND   PERI-OOPHORITIS — ABSCESS   OF   OVARY.    115 

will  be  almost  certainly  prescribed.  No  wonder  that  such  rou- 
tine practice  frequently  fails  ;  for  a  very  considerable  number 
of  cases  of  monorrhagia  which  come  up  for  treatment  are  of  the 
kind  we  have  been  considering,  and  for  such  as  these  the  per- 
salts  of  iron  are  worse  than  useless  ;  their  only  effect  will  prob- 
ably be  to  aggravate  the  complaint, "  The  paper  from  which  I 
quote  Dr.  Meadows'  words  is  one  on  ''  Ovarian  Menorrhagia."' 

Among  our  private  patients,  in  spite  of  every  kind  of  treat- 
ment, no  matter  how  long  a  time  it  may  be  continued,  we  shall 
find  a  few  cases  in  which  no  good  result  is  obtained,  and  these 
can  only  be  dealt  with  by  the  last  resort  of  a  surgical  operation. 
Among  our  hospital  patients,  on  the  contrary,  the  cures  are  ex- 
ceptional and  the  failures  are  the  rule,  solely  for  the  reason  that 
these  poor  women  cannot  fulfil  the  necessary  conditions.  This 
part  of  the  treatment  I  shall  discuss  at  length  in  the  chapter  on 
ovariotomy. 

As  one  of  the  results  of  chronic  ovaritis,  we  get  pronounced 
hypertrophy  of  the  glands,  and  this  occurs  distinctly  in  two 
forms,  as  it  affects  the  follicles  of  the  gland  or  its  fibrous  tissue. 
There  may  be,  as  Dr.  Ritchie  and  Dr.  Fox  have  pointed  out,  an 
increased  formation  of  the  number  of  follicles  ;  this,  in  all  prob- 
ability, being  a  pathological  feature  of  the  ovarian  hypersemia  I 
have  described.  Follicular  hypertrophy  may  take  the  form  of 
increase  in  size  of  individual  follicles,  and  constitute,  as  first 
shown  by  Rokitansky,  a  variety  of  cystic  growth ;  and  this  is, 
as  both  Dr.  Duncan  and  myself  have  pointed  out,  a  frequent 
character  of  the  ovaries,  which  have  to  be  removed  on  account 
of  the  suffering  inflicted  by  chronic  ovaritis. 

In  fact,  there  seems  to  be  a  close  and  hitherto  unsuspected 
connection  between  cystic  disease  of  the  ovary  and  some  of  the 
most  severe  uterine  symptoms  that  patients  suffer  from.  Thus, 
I  have  removed  the  ovaries  of  a  large  number  of  women  suffer- 
ing from  profuse  and  destructive  hemorrhage,  due  to  the  pres- 
ence of  uterine  myoma,  and  in  the  majority  of  these  cases  I  have 
found  the  ovaries  cystic.  But  it  may  be  noticed  that  these  cysts 
have  not  always  been  like  the  large  tumors  for  which  we  per- 
form ovariotomy,  and  the  ovaries  containing  them  have  very 
often  been  no  larger  than  walnuts.  In  them  the  ovarian  tissue 
had  been  replaced  by  cysts,  and  when  those  cysts  were  emptied 
there  was  very  little  left  besides  their  walls.  On  the  other  hand, 
some  of  the  cystic  ovaries  in  these  cases  of  myoma  had  attained 
quite  a  large  size,  so  that  there  has  arisen  a  difficulty  in  deciding 
as  to  whether  one  was  operating  for  the  removal  of  cystic  ova- 
nes,  or  removing  the  ovaries  for  the  purpose  of  arresting  hemoT- 
rliage  in  cases  of  myoma.     Indeed,  the  difficulty  was  to  say 


IIG  DISEASES   OF   THE   OVARIES. 

whether  it  was  a  case  of  ovariotomy  or  the  so-called  "  oophorec- 
tomy." The  result  has  been,  as  I  shall  state  at  length  in  another 
chapter,  that  I  have  completely  discarded  the  use  of  this  latter 
term,  because,  unless  some  kind  of  conventional  distinction  is 
made,  it  will  be  perfectly  impossible  to  classify  our  cases  in  any 
logical  manner,  or  for  any  useful  purpose. 

These  small  cystic  ovaries  very  often  give  rise  to  extremely 
severe  hemorrhage,  even  when  there  is  no  myoma  present,  and 
when  there  is  no  suspicion  of  any  chronic  inflammation  of  the 
glands.  The  size  of  the  ovaries  is  not  great  enough  to  justify  us 
in  calling  them  ovarian  tumors,  and  it  is  highly  probable  they 
are  nothing  more  than  follicular  hypertrophies.  Of  this  peculiar 
condition  I  propose  here  to  give  in  detail  three  instances. 

In  June,  1880. 1  was  called  by  Dr.  Collis,  of  Bridgenorth,  to  see 
with  him.  in  consultation,  a  lady  of  very  eminent  social  position, 
on  account  of  persistent  metrorrhagia.  She  was  twenty- nine 
years  of  age.  She  had  been  married  six  years,  and  before  that 
had  suffered  always  more  or  less  from  a  white  discharge  and  ir- 
regular and  profuse  menstruation.  Nine  months  after  marriage 
she  was  confined  of  a  still-born  child,  and  nearly  lost  her  life 
from  hemorrhage.  Two  years  after  she  had  another  child,  liv- 
ing, and  in  the  following  year  another  child,  both  labors  being 
characterized  by  unusual  hemorrhage.  In  1878  she  had  a  mis- 
carriage, and  was  alarmingly  ill  from  hemorrhage.  In  August, 
1879,  a  third  child  was  born,  about  six  weeks  before  the  full  time, 
when  again  the  hemorrhage  was  extreme. 

Dr.  Collis  has  favored  me  with  the  following  notes  of  the 
progress  of  this  most  interesting  case  :  He  saw  her  first  on  May 
131,  1880,  when  he  was  informed  that,  up  to  a  fortnight  before 
his  visit,  she  had  missed  three  menstrual  periods,  but  that  during 
the  fortnight  there  had  been  a  continuous  flow.  Neither  she  nor 
her  husband  thought  it  possible  that  she  was  pregnant.  They 
regarded  it  as  her  usual  profuse  and  protracted  menstruation  ; 
but  on  examination  Dr.  Collis  found  the  uterus  enlarged.  He 
kept  her  in  bed  and  gave  her  astringents,  and  afterward  ergot 
and  bromide  of  potash.  Finally  lie  luid  to  plug  the  vagina,  and 
then  he  telegraphed  for  me  to  see  her  with  him.  I  saw  her  on 
the  evening  of  June  13th,  and  found  the  patient  very  anaemic, 
and  the  uterus  enlarged  as  if  by  a  pregnancy  of  the  third  month. 
The  cervix  being  closed,  it  was  clear  that  we  must  dilate,  and 
for  that  purpose  I  introduced  my  instruments,  which  act  by  con- 
tinuous elastic  pressure.  In  a  few  hours  dilatation  had  proceeded 
so  far  that,  after  placing  the  patient  under  ether,  I  was  able  to 
empty  the  uterus  of  a  large  quantity  of  clot  and  some  villous 


OOPnORlTIS   AND   PEKI-OOPHOKITIS — ABSCESS   OF   OVAIIY.    117 

cysts.  These,  I  presume,  were  remains  of  a  chorion  of  which 
the  villi  had  undergone  cystic  dilatation,  but  nothing  in  the  shape 
of  membranous  or  placental  structure  could  be  discovered.  Rec- 
ognizing- the  urgent  necessity  of  there  being  no  more  hemor- 
rhage, I  took  great  pains  to  remove  everything  from  the  uterus, 
and  I  scraped  the  whole  of  the  inner  surface  over  with  a  curette. 
She  had  no  further  loss,  and  made  a  good  recovery  till  July  10th, 
wlien  her  period  came  on  very  profusely,  lasted  ten  days,  and 
left  her  very  anaemic  and  exhausted.  During  the  whole  time 
she  took  large  doses  of  bromide  of  potash  and  ergot,  but  with  no 
apparent  effect.  Hemorrhage  again  occurred  on  July  29th,  by 
which  time  she  had  been  removed  to  Malvern,  where  she  was 
under  the  care  of  Drs.  Pike  and  Weir.  The  hemorrhage  was 
extreme,  and  everything  was  tried,  including  hypodermic  injec- 
tions of  ergotin,  without  any  avail.  I  was  sent  for  on  August 
.3d,  and  found  the  patient  in  the  very  last  stage  of  anaemic  ex- 
haustion. I  removed  a  plug  which  had  been  placed  in  the  va- 
gina, found  the  uterus  perfectly  small  and  normal,  explored  it 
with  the  alligator-forceps,  but  found  nothing  in  it,  and  then  I 
applied  solid  nitrate  of  silver  freely  to  the  inside.  This  stopped 
the  hemorrhage  for  about  twenty  hours,  but  after  that  it  came 
on,  and  I  was  sent  for  again  on  the  6th.  At  my  visit  on  the  3d 
I  had  informed  the  husband  that,  if  the  nitrate  of  silver  did  not 
check  the  hemorrhage,  I  knew  nothing  short  of  a  surgical  opera- 
tion which  would,  but  said  nothing  to  him  as  to  the  nature  of  the 
operation  I  intended  to  perform.  When  telegraphed  for  on  the 
Cth,  I  replied  that  I  should  bring  my  assistant  and  everything 
prepared  to  operate  if  it  was  thought  desirable,  and  for  this  pur- 
pose my  friend,  Dr.  J.  W.  Taylor,  accompanied  me  to  Malvern, 
in  the  absence  of  Mr.  Raffles  Harmar. 

When  I  reached  the  house  I  met  the  husband,  a  man  of  dis- 
tinguished position  and  great  intelligence,  at  the  door.  He 
greeted  me  with  the  remark  that  he  did  not  know  what  I  pro- 
posed to  do,  that  he  left  it  entirely  to  me,  but  that  he  was  per- 
fectly sure  the  only  thing  which  would  give  either  temporary  or 
permanent  relief  would  be  removal  of  the  appendages.  As  this 
was  exactly  my  own  notion,  and  was  readily  agreed  to  by  my 
■colleagues  in  the  case,  I  at  once  proceeded  to  carry  it  out,  my  only 
fear  being  that  we  had  delayed  it  too  long.  She  was  blanched 
beyond  my  powers  of  language  to  describe,  and  she  had  those 
■swollen,  waxy  lips  which  are  rarely  restored  to  their  original 
condition.  There  was  no  difficulty  in  the  operation,  and  both 
ovaries  were  found  to  be  cystic,  and  about  the  size  of  Mandarin 
oranges.  The  uterus  was  perfectly  normal  in  size  and  consis- 
tence when  I  had  it  between  my  fingers.     The  incision  was  only 


118  DISEASES   OF   THE   OVARIES. 

two  and  one-half  inches  long,  and  its  bleeding  points  were  indi- 
cated by  a  flow  of  serum  almost  devoid  of  color.  For  about  an 
hour  after  the  operation  I  gave  up  almost  all  hope  of  her  recov- 
ery. Dr.  Pike  and  I  were  in  almost  constant  attendance  upon 
her  for  five  days,  during  which  she  had  some  ups  and  downs, 
but  finally  she  got  right,  and  has  never  lost  a  drop  of  blood  since. 
She  has  had  the  usual  flushes  and  other  slight  indications  of  the 
climacteric,  but  these  are  wearing  off ;  and  in  the  last  letter  I 
have  had  from  her  husband,  a  few  days  ago,  is  the  sentence:  '"It 
only  remains  for  me  to  express  our  united  gratitude  for  your 
skill  and  attention ;  for,  humanly  speaking,  I  shall  always  look 
upon  you  as  her  saviour." 

Putting  aside,  as  far  as  possible,  all  personal  gratification  at 
such  an  expression,  I  desire  only  to  put  in  this  evidence  given  by 
a  highly  educated  layman,  fully  conversant  with  his  wife's  con- 
dition and  what  was  done  for  her,  in  favor  of  an  operation  upon 
which  only  those  who  have  not  successfully  tried  it  are  endeav- 
oring to  cast  obloquy.  The  only  credit  in  this  case  I  desire  to 
assume  is,  that  I  had  the  courage  of  my  convictions,  and  that  I 
proceeded,  as  a  last  resource,  to  a  step  which,  if  I  had  regard  to 
metropolitan  opinions,  I  should  not  have  attempted.  Had  the 
case  been  unsuccessful,  the  position  of  the  patient  was  such  that 
the  proceeding  would  have  been  widely,  and  I  fear  adversely, 
criticised. 

Looking  at  the  ovaries  of  this  case,  I  notice  that  there  is  little, 
if  any  real  ovarian  tissue  left.  There  is  hardly  anything  but  the 
thin  walls  of  a  number  of  dilated  follicles,  from  which  it  is  very 
difficult  to  believe  that  a  healthy  ovum  could  be  sent  into  the 
tube.  This  naturally  raises  the  question  as  to  whether  the  im- 
perfect ovulation,  which  was  the  first  cause  of  my  being  sent  for 
to  her,  was  the  result  of  this  follicular  hypertrophy.  I  think  it 
very  likely  that  it  was  so.  The  condition  seen  in  these  ovaries 
must,  I  think,  bo  something  special,  and  not  merely  the  early 
stage  of  cystoma,  for  I  never  hear  such  a  terrible  story  of  hem- 
orrhage from  the  lips  of  a  patient  in  whom  an  ordinary  cj'-stoma 
has  grown,  as  I  have  to  narrate  about  the  three  cases  in  whom 
I  found  these  small  cystic  ovaries,  and  from  whom  I  removed 
them  with  perfect  success. 

The  second  case  was  in  some  respects  more  remarkable  than 
the  first,  though  it  is  not  necessary  to  occupy  so  much  space 
with  its  detail.  She  was  thirty-nine  years  of  age,  had  been 
married  at  fourteen  years  of  age,  and  was  confined  of  her  first 
child  before  she  was  sixteen,  her  second  at  seventeen  ;    eight 


OOPHORITIS    AND    PEKI-OOPilOULTIS — ABSCESS    OF    OVAUY.    119 

months  after  she  had  a  miscarriage,  and  then  for  the  next  ten 
years  had  a  baby  every  year.  At  each  confinement  the  hem- 
orrhage was  very  great,  and  two  or  three  times  she  was  sup- 
posed to  be  dying  from  this  cause.  As  she  had  had  no  menstrua- 
tion for  twelve  years,  being  either  always  pregnant  or  suckling, 
she  could  tell  nothing  about  this  matter  until  she  became  a 
widow  at  twenty-eight.  She  married  again  about  four  years 
ago,  and  during  lier  widowhood  her  menstruation  had  been  far 
too  frequent  and  too  profuse,  and  she  had  been  ahnost  con- 
stantly in  the  doctors  hands  on  that  account.  Since  her  recent 
marriage  she  has  had  eight  miscarriages  in  forty  months,  the 
first  being  at  seven  months  and  the  others  between  four  and  five. 
She  was  admitted  into  the  liospital  in  February  last,  when  preg- 
nant at  the  third  month.  She  was  put  upon  chlorate  of  potash 
and  biniodide  of  mercury,  in  order  to  avoid  the  repetition  of  the 
miscarriage,  and  she  took  every  precaution  to  assist  us  in  this, 
for  both  she  and  her  husband  were  very  anxious  for  a  living 
child.  In  spite  of  everything,  however,  she  miscarried  at  the 
fifth  month,  and  as  nearly  as  possible  died  from  the  hemorrhage. 
During  May,  June,  and  July  she  had  most  profuse  menstruation, 
though  active  treatment  was  employed,  and  when  admitted  into 
hospital  again  she  was  a  completely  broken-down  ansemic  wo- 
man, whose  desire  was  to  die  if  nothing  more  could  be  done  for 
her.  In  this  case  it  did  not  occur  to  me  to  remove  the  appendages, 
and  that  proposal  originated  with  my  colleague.  Dr.  Hickinbo- 
tham,  at  the  consultation  held  on  the  case.  I  am  bound  to  say 
I  did  not  regard  the  idea  with  favor  at  first,  and  it  was  only  after 
prolonged  discussion  Avith  my  colleagues,  and  finally  at  the  ear- 
nest and  frequently  repeated  request  of  the  patient  herself,  that 
I  undertook  it.  This  request  was  based  on  her  knowledge  de- 
rived from  a  patient  in  the  same  ward  who  was  recovering  from 
the  operation.  Here  again  the  ovaries  were  cystic,  just  as  in 
the  first  case,  the  cysts  being  small  and  thin- walled,  but  occupy- 
ing the  whole  of  the  ovary.  We  may  again  ask,  Did  they  ac- 
count for  the  repeated  incomplete  ovulation,  as  well  as  the  hem- 
orrhage ?  Such  a  question  needs  a  much  wider  experience  for 
its  solution.  Whatever  be  the  explanation,  the  result  is  brilliant, 
for  the  woman  made  a  speedy  recovery,  and  now,  not  yet  twelve 
months  since  the  operation,  is  in  robust  health — such  health,  in 
fact,  as  she  has  never  known  before. 

The  third  case  was  sent  to  me  by  Dr.  Meredith,  of  Wel- 
lington, in  Somersetshire,  and  I  give  the  history  in  his  own 
words  : 

''  In  May,  1877, 1  had  to  attend  a  young  woman,  aged  twenty, 


120  DISEASES   OF   THE   OVARIES. 

on  account  of  excessive  menstrual  discharge,  which  had  been 
going  on  for  some  weeks. 

' '  The  previous  history  of  the  case  was  briefly  this  :  The  pa- 
tient, as  a  girl,  had  always  been  considered  delicate  up  to  the 
menstrual  period — which,  with  her,  began  when  she  was  fifteen 
— although  she  was  well-formed  and  tall.  Once  the  courses  be- 
came established,  she  began  to  gain  strength  and  fatten.  The 
catamenia  were  regular,  but  scanty;  only  about  three  diapers  at 
a  period  ;  still  she  felt  well,  and  gave  this  no  particular  thought. 
Her  parents  are  healthy,  and  so  are  her  brothers  and  sisters. 
One  day  in  March  of  the  year  mentioned  (1877),  while  menstru- 
ating, she  assisted  in  lifting  a  book-case.  She  felt  the  effort  af- 
fecting her,  and  the  discharge,  instead  of  terminating  at  the  ex- 
pected time,  went  on  day  after  day. 

"  When  I  saw  her  she  was  in  an  exhausted  condition  from  the 
loss,  and  suffering  pain,  etc.,  in  the  lower  part  of  the  abdomen, 
indicating  the  presence  of  a  certain  amount  of  local  inflamma- 
tory action.  After  the  administration  of  opiates  this  condition 
of  irritability  subsided,  and  after  a  while  I  obtained  permission 
to  make  a  digital  examination  of  the  vagina  and  cervix  uteri. 

'■'  The  information  I  got  from  this  was  that  there  was  no 
appreciable  difficulty  in  introducing  the  finger ;  the  os  uteri  was 
patulous,  with  a  blood-clot  in  it,  and  the  cervix  elongated.  There 
was  nothing  special  to  note  in  regard  to  the  condition  of  the 
uterus — no  marked  version  or  flexion.  Now,  a  very  natural 
question  suggested  itself,  and  I  have  no  doubt  it  arises  at  once 
in  your  minds,  namely.  Was  not  the  case  one  of  miscarriage  ? 
A  question  which  I  put  to  the  patient  some  time  afterward,  bear- 
ing on  this,  was  met  by  a  negative  answer — just  what  I  might 
have  expected.  But  my  duty  was  to  arrest  the  hemorrhage  and 
bring  about  recovery,  if  I  could.  To  this  end  I  administered 
ergot,  acids,  bromide  of  potassium,  chlorate  of  potash,  digitalis, 
and  cannabis  indica.  The  last-named  three,  in  combination, 
seemed  to  answer  well  for  a  while,  then  there  would  be  a  relapse. 
Cloths  dipped  in  vinegar  and  water  were  applied  over  the  vulva 
and  lower  part  of  the  abdomen  ;  cold  water,  vinegar  and  water, 
and  carbolic  acid  solution  were  at  intervals  injected  into  the  va- 
;;ina,  and,  of  course,  absolute  rest  in  bed  was  enjoined,  witL 
<  verything  cold  in  the  way  of  food  and  drink. 

"  In  spite  of  everything,  the  discharge  continued  more  or  less 
until  July.  At  times  there  would  be  nothing  but  a  pink,  san- 
{•uineous  staining  on  the  cloth.  The  patient  soon  learned  to  dis- 
like this  appearance,  as  she  had  always  a  great  deal  of  backache 
with  it,  from  which  she  was  only  relieved  after  the  expulsion  of 
blood-clots.     The  explanation  of  this,  I  take  it,  was  that  the  clo6 


OOPIIOIIITIS   AND   PEKI-OOPIIOEITIS — ABSCESS   OF   OV^AKY.   121 

formed  in  the  os  uteri,  and,  owing  to  the  flow  not  being  enough 
at  times  to  carry  itself  off  as  a  whole,  the  fibrin  sejjarated  at  the 
uterine  outlet  and  in  the  uterus  as  well,  staying  there  gathering 
in  volume,  while  the  liquor  sanguinis  escaped,  and  produced  the 
stains  mentioned.  The  fibrinous  part,  in  thickening,  rested  upon 
the  walls  of  the  os,  distending  it,  and,  as  in  labor  or  any  other 
form  of  tension  at  the  os  uteri,  the  discomfort  was  referred  to 
the  sacral  region — the  region  of  backache  with  many  women. 
After  going  on  in  this  way  for  a  time,  I  decided  to  apply  pure 
carbolic  acid  to  the  interior  of  the  uterus.  I  did  this  in  the  usual 
way,  by  means  of  a  piece  of  cotton-wool  wrapped  around  an  or- 
dinary uterine  sound.  The  result  was  satisfactory  for  the  time ; 
the  discharge  stoi^ped  for  five  months,  the  patient  recovered 
strength,  and  was  able  again  to  go  about  and  enjoy  herself. 

''■  In  the  beginning  of  1878  the  menses  reappeared,  but  nothing 
much  to  complain  of  at  first ;  then  the  loss  assumed  a  more  per- 
sistent character.  Drugs  seemed  to  have  very  little  influence 
now,  nor  had  the  intra-uterine  application  of  carbolic  acid  the 
same  arresting  influence  as  at  first ;  still  it  exercised  a  certain 
amount  of  staying  jjower.  Thus  matters  went  on  unsatisfacto- 
rily to  all  concerned.  Toward  the  end  of  1878  the  loss  was  not 
very  great,  still  it  recurred  at  short  intervals  ;  but  on  Christmas 
eve  she  got  excited  with  some  of  her  friends,  and  then  it  came 
on  profusely.  There  was  always  tenderness  over  the  ovaries,  at 
times  more  over  one  than  the  other,  and,  of  course,  the  usual 
sympathetic  tenderness  along  the  spine. 

*'  Finding  that  I  was  unable  to  afford  the  relief  I  wished,  I 
urged  the  patient  to  go  to  the  Women's  Hospital  at  Birmingham, 
to  be  under  the  care  of  Mr.  Lawson  Tait,  with  whom  I  had  had 
some  correspondence  regarding  the  case.  Accordingly,  on  Janu- 
ary 15th  she  went  thither.  She  was  thin,  weak,  and  anaemic  at 
the  time.  A  few  days  afterward  I  had  a  note  from  Mr.  Tait, 
saying  that  he  had  dilated  the  uterus  and  thoroughly  explored 
it,  and  could  find  nothing  amiss  with  it,  only  that  the  fundus 
was  a  little  enlarged,  nothing  more. 

.  "A  few  days  after  admission,  nitrate  of  silver  was  applied  to 
the  cavity  of  the  womb,  and  repeated  three  times  between  that 
and  February  15th.  On  the  19th  the  loss  ceased,  and  no  further 
application  was  made.  The  patient  had  mixtures  given  her,  con> 
sisting  of  ergot,  bromide  of  potassium  or  chlorate  of  potash,  and, 
after  the  cessation  of  the  discharge,  dialyzed  iron. 

"  She  left  the  hospital,  apparently  recovered,  on  March  1st,  and 
went  to  a  convalescent  home,  where  she  stayed  for  some  time  and 
was  much  improved.  In  due  course  she  returned  home  to  Well- 
ington.    On  the  night  of  her  return  the  discharge  began  again. 


122  DISEASES   OF   THE   OVARIES. 

"  I  knew  nothing  of  her  return,  or  of  the  recurrence  of  the  dis- 
charge, until  she  had  been  at  home  for  some  weeks.  During  the 
interval  she  tried  the  effects  of  medicines  which  some  neighbors 
procured  for  her — getting  into  a  sort  of  desperation-state,  which 
we  can  all  pardon  under  the  circumstances.  I  now  tried  the  ef- 
fects of  cold  water  hip-baths,  and  with  some  apparent  good  re- 
sults. Mustard  poultices  over  the  ovaries  were  followed  by  no 
marked  benefit.  Swabbing  the  interior  of  the  uterus  produced 
some  relief.  After  a  time  I  introduced  a  piece  of  nitrate  of  silver 
into  the  cavity  of  the  uterus,  and  left  it  there.  This  altered  the 
character  of  tlie  discharge;  but,  in  spite  of  all,  the  loss  persisted. 
I  frequently  left  her  alone,  desiring  her  to  keep  still  and  take  no 
medicines  at  all;  the  result  was  the  same — always  losing. 

"On  July  Oth  last  I  gave  her  a  liypodermic  injection  of  ergo- 
tine,  which  was  followed  by  a  stoppage  of  the  discharge  for 
about  three  weeks.  On  August  5th  I  again  sent  her  to  the  Wo- 
men's Hospital  at  Birmingham,  imder  the  care  of  Mr.  Tait.  At 
the  time  the  patient  was  antemic,  thin,  and  weak,  and  hardly 
able  to  stand." 

I  re-admitted  the  patient  in  August,  1870,  and  removed  both 
ovaries  on  the  8th  of  that  month.  Tlie  ovaries  were  large  and 
flabby,  and  occupied  by  a  number  of  distended  follicles  forming 
cysts.  They  were  also  chronically  inflamed,  for  there  was  evi- 
dence of  old  lymph  here  and  there  on  their  surfaces,  and  they 
were  somewhat  adherent.  The  patient  went  home  in  a  few  weeks 
after  the  operation,  and  speedily  gained  health  and  strength. 
She  has  never  menstruated  since,  and  enjoys  perfect  health 
(May,  1882). 

From  these  cases  I  am  forced  to  conclude  that  between  these 
small  cystic  ovaries  and  uncontrollable  hemorrhage  there  is  some 
connection  which  has  yet  to  be  studied,  and  tliat  in  such  cases 
the  removal  of  the  ovaries  is  not  only  to  be  justified,  but  that  it 
is  the  proper  proceeding,  the  results  of  these  cases  having  been 
brilliantly  successful. 

Besides  this  follicular  hypertrophy,  tliere  is  a  distinct  form  of 
fibrous  hyperplasia  which  is  probably  tlie  result  of  that  form  of 
chronic  ovaritis  which  attacks  the  fibrous  element,  and  results  in 
follicular  destruction  or  arrest  of  development  of  the  proper  ova- 
rian cells,  and  produces  an  excess  of  the  trabecular  structure. 
It  is,  in  fact,  the  process  of  cirrhosis  in  its  second  stage,  previous 
to  the  contraction.  The  following  is  a  case  which  I  have  had 
the  opportunity  of  watching  for  many  years,  and  now  seems  to 
be  verging  toward  the  cirrhotic  condition.  Both  the  patient 
and  I  are  agreed  that  if  I  could  luive  done  for  her  ten  years  ago 


OOPHORITIS    AND   PERI-OOPHORITIS — ABSCESS   OF   OVARY.    12: J 

what  I  could  do  now,  if  it  were  as  necessary,  she  would  elect 
to  have  her  ovaries  removed  rather  than  pass  through  the  pro- 
longed invalidism  to  which  she  has  been  subjected.  She  belongs 
to  the  upper  ranks  of  life,  and  therefore  has  had  every  opportu- 
nity of  recovering,  and  no  money  has  been  spared  to  secure  her 
good  health;  yet  she  has  been  an  invalid  for  about  twelve  years, 
and  is  so  yet,  though  enjoying  better  health  than  she  did  three 
years  ago.  It  would  have  been  cheaper  for  her,  and  better  in 
every  way,  to  have  had  her  ovaries  removed  ten  years  ago. 

She  is  now  about  thirty-eight  years  of  age,  is  a  pretty,  deli- 
cate blonde  of  nervous  temperament  and  most  refined  cast  of 
features,  and  has  been  married  about  eight  years.  She  has  a 
history  of  hypersemia  of  the  ovaries  at  an  early  age,  and  has  had 
always  very  profuse,  and  generally  irregular,  menstruation  until 
within  the  last  three  or  four  years,  when  it  has  been  scantier 
and  less  frequent.  From  November,  1871,  until  she  came  under 
my  care,  she  had  had  only  one  normal  period  (in  seven  months), 
and  another  in  April,  1872.  From  the  former  date  a  constant, 
offensive,  brown  discharge  had  been  present,  which  was  in- 
creased by  exertion.  She  had  pain  and  straining  after  coitus, 
pain  on  defecation,  loss  of  appetite,  and  frequent  sickness.  Ex- 
amination revealed  a  condition  of  enlargement  and  tenderness 
of  the  uterus,  openness  of  the  cervix,  and  decided  retroflexion  of 
the  fundus,  with  a  tendency  to  retroversion  of  the  whole  organ. 
The  cavity  was  not  larger  than  normal,  but  the  passage  of  the 
sound  gave  great  pain.  The  displacement  was  easily  reduced, 
and  then  it  was  found  that  both  ovaries  were  very  much  en- 
larged and  tender,  the  left  especially.  They  could  both  be  dis- 
tinguished by  bimanual  touch  as  quite  free  from  adhesion, 
readily  moving  about.  I  introduced  a  ring-pessary  to  rectify 
the  displacement,  much  to  her  comfort,  and  directed  the  use  of 
iodine-paint  in  the  manner  previously  described.  She  also  took 
a  tonic  mixture  consisting  of  cinchona  and  angostura,  and  the 
uterine  cavity  was  occasionally  washed  out  with  a  weak  solution 
of  neutral  acetate  of  lead.  The  latter  part  of  the  treatment  was 
discontinued  after  a  few  months,  but  the  counter-irritation  and 
the  pessary  were  persevered  in,  along  with  occasional  recourse 
to  tonics.  In  October,  1875,  the  brown  discharge  had  almost  dis- 
appeared, and  the  right  ovary  could  be  felt  to  have  distinctly 
diminished  in  size.  The  uterus  was  also  straight  and  the  cervix 
closed,  and  the  whole  organ  of  a  much  less  size.  Early  in  No- 
vember there  was  a  slight  menstruation  lasting  three  days,  and 
in  January  of  this  year  there  occurred  quite  a  normal  period  of 
four  days,  followed  by  rather  profuse  leucorrhoea.  In  February, 
as  the  expected  period  did  not  occur,  I  ordered  her  small  doses  of 


124  DISEASES   OF   THE   OVAKIES. 

iron,  in  the  form  of  ten  drops  of  Parrish's  syrup  of  the  phos- 
phates, taken  thrice  daily. 

For  tlie  last  five  years  the  treatment  has  been  varied,  both  by 
myself  and  others,  but  nothing  seemed  to  have  any  very  marked 
effect,  unless  it  be  residence  at  Kreuznach  and  the  prolonged 
use  of  the  waters.  Nature  seems  to  be  working  her  own  cure, 
and  the  only  question  to  be  discussed  is:  Would  it  not  be  better, 
in  such  a  case  as  this,  to  run  a  slight  risk  in  the  removal  of  the 
ovaries,  and  so  effect  a  speedy  and  permanent  cure  ?  I  think  it 
would,  and  so  does  my  patient. 

There  is  probably  a  chronic  ovaritis  of  occasional  occurrence 
in  chronic  phthisis;  for,  though  the  rule  in  that  disease  is  to  have 
ovarian  atrophy,  evinced  first  in  dysmenorrhoea  and  finally  in 
amenorrhoea,  yet  I  have  seen  a  few  cases  where  the  menstrua- 
tion was  profuse,  irregular,  and  characterized  by  the  other 
symptoms  of  chronic  ovaritis.  1  have  seen  such  conditions  tem- 
porarily after  small-pox,  and  frequently  after  scarlet  fever  in 
adolescent  women.  One  case  I  have  also  satisfied  myself  of  in 
t;arly  acquired  syphilis.  There  is  a  distinct  form  of  syphilitic 
metritis,  as  pointed  out  long  ago  by  Mr.  Langston  Parker,  and 
no  doubt  in  these  cases  the  ovaries  are  involved. 

Arthur  Farre  has  noticed  an  intense  red  coloring  of  the  ova- 
ries in  cardiac  disease,  and  I  have  more  than  once  found  that  in- 
tractable menorrhagia  had  apparently  its  origin  in  valvular  dis- 
ease of  the  heart,  or  at  least  was  closely  associated  with  it,  in 
such  cases  there  being  often  no  discoverable  lesion  of  either  ute- 
rus or  ovaries. 

I  have  met  with  a  small  group  of  cases  which  I  can  only  class 
under  the  head  of  ovarian  neuralgia.  They  have  been  charac- 
terized by  acute  lancinating  pain  referred  to  the  region  of  the 
ovaries,  generally  on  both  sides,  coming  on  jjaroxysmally,  with- 
out any  reference  to  the  uterine  or  ovarian  functions.  No  physi- 
cal signs  of  disease  have  been  found  in  these  cases,  and  they  have 
all  occurred  in  women  approaching  the  menopause.  They  have 
all  been  addicted  to  outbursts  of  over-indulgence  in  drink,  taken, 
as  they  allege,  to  deaden  the  pain.  Whether  this  inebriety  was 
a  cause  or  a  result  of  the  neuralgia,  or  whether  the  neuralgia  in 
some  of  the  cases  may  have  had  any  actual  existence,  I  am  un- 
able to  say;  though  tlie  special  character  of  the  pain  and  its  site 
have  been  described  by  the  sufferers  with  a  constancy  which 
would  seem  to  vouch  for  its  reality.  In  connection  with  this 
affection  I  would  here  urge  the  necessity  for  the  medical  pro- 
fession combating  strongly  against  the  wrong  women  are  often 
allowed  to  do  themselves  by  taking  spirits  to  relieve  ovarian 
iiiid  menstrual  pain.     No  habit  can  be  more  pernicious,  or  more 


OOPnOHITI.S    AND   PERI- OOPHORITIS — ABSCESS    OF    OVARY.    125 

likely  to  lead  to  the  most  deadly  mischief,  l)otli  j)liysical  and 
moral. 

A  singular  condition  has  been  noticed  by  Dr.  Priestley,  of 
intermenstrual  pain,  occurring-  about  midway  between  the  peri- 
ods, which  is  almost  certainly  due  to  an  ovarian  condition, 
though  it  is  not  clear  of  what  kind.  Since  reading  his  paper  I 
have  seen  several  cases,  but  have  been  unable  to  refer  them  to 
any  category. 

Abscess  of  the  ovary  is  a  condition  of  extreme  rarity,  or,  at 
least,  it  certainly  is  one  which  we  can  rarely  diagnose  during 
life,  and  in  the  majority  of  instances  probably  death  occurs  from 
the  rupture  of  the  abscess  into  the  peritoneum,  without  any  di- 
agnosis having  been  made  beyond  that  comprised  in  the  generic 
term  of  an  attack  of  "  inflammation  of  the  bowels,"  under  which 
category  a  large  number  of  cases  are  entered  in  the  death  regis- 
ter, many  of  which  probably  might  have  been  relieved  if  a  more 
accurate  diagnosis  had  been  possible.  Of  the  cases  of  abscesses 
of  the  ovary  which  recover  after  ruj)ture  we  of  course  only  find 
subsequent  traces  in  the  indications  of  old  perimetritis  which  are 
usual  after  a  great  many  other  lesions  as  well  as  this.  Probably, 
however,  the  larger  number  of  cases  which  have  been  published 
as  abscesses  of  the  ovary  are  nothing  more  than  suppuration  in 
ovarian  cysts,  and  therefore  belong  to  an  altogether  different 
category  from  those  of  which  I  am  now  speaking. 

True  abscess  of  the  ovary  is  said  to  occur  most  frequently  in 
connection  with  i^elvic  suppuration  of  the  puerperal  woman,  and 
possibly  this  may  be  a  condition  of  pretty  frequent  occurrence. 
I  have,  however,  for  many  years  past,  carefully  avoided  attend- 
ing post-mortem  examinations  of  such  cases,  and  therefore  I 
have  seen  no  instance  of  this  kind.  The  only  cases  of  abscess  of 
the  ovary,  in  clinical  experience,  of  which  I  have  been  certain, 
are  two,  one  of  which  I  have  already  narrated  under  the  head  of 
pyosalpinx;  and  the  second  is  one  of  great  interest  because  it 
also  shows  what  immense  success  has  been  recently  made  possi- 
ble by  the  advances  of  abdominal  surgery. 

The  patient  was  sent  to  me  by  Dr.  Lycett,  of  Wolverhampton^ 
and  I  cannot  do  better  than  give  the  history  of  the  case,  which 
he  sent  to  me  in  a  letter,  as  being  quite  a  model  of  what  such 
communications  should  be.     It  was  as  follows: 

"  She  is  about  thirty-eight  years  of  age,  and  has  suffered  for 
many  years  from  great  ovarian  pains,  rarely  free,  and  much  in- 
creased at  the  menstrual  period,  which  are  often  fortnightly, 
scanty,  and  prolonged  for  a  week  or  ten  days.  The  left  ovary 
seems  the  one  at  fault,  being  tender  and  somewhat  enlarged; 
the  uterus  is  rather  conical,  but  the  passage  fairly  patent.     She 


126  disp:asks  of  the  ovakies. 

has  had  a  variety  of  treatment  under  my  hands,  and,  though  able 
to  afford  some  rehef,  yet  I  see  no  prospect  of  permanent  good, 
so  that  at  last  I  am  desirous  of  your  opinion  as  to  oophorectomy, 
for  her  health  has  materially  suffered,  as  you  will  observe.  She 
is  a  weakly,  nervous.  ana3mic  person,  whose  life  is  a  misery,  and 
may  probably  break  down  before  the  menopause.  She  has  not 
had  any  children.  Several  times  at  the  periods  her  temperature 
has  risen  to  even  102°,  marking  some  local  inflammation,  and  at 
these  times  the  pain  and  tenderness  is  greater."' 

No  history  could  be  more  graphic,  concise,  and  complete. 
The  only  additions  I  can  make  to  it  are  that  marital  life  was  ab- 
solutely unendurable,  and  that  I  found  the  left  ovary  adherent 
in  the  cul-de-sac. 

I  quite  concurred  with  Dr.  Lycett's  views,  and  with  his  con- 
currence and  assistance  I  performed  ovariotomy  on  June  28th. 
I  found  the  left  ovary  firmly  adherent  in  front  of  the  rectum, 
and  to  pull  it  off  from  its  attachment  was  a  work  of  difficulty. 
It  contained  about  two  drachms  of  pus,  and  appeared  to  be  just 
on  the  ijoint  of  bursting  into  the  peritoneal  cavity.  Had  it  so 
burst,  she  doubtless  would  have  had  an  attack  of  acute  peritoni- 
tis, from  which  she  might  have  died.  The  right  ovary  was  shriv- 
elled, so  I  removed  that  also.  She  made  a  perfect  recovery,  and 
not  only  is  cured,  but  her  sexual  relations  are  now  possible. 
no  that  not  only  has  removal  of  the  ovaries  not  unsexed  her, 
but  it  positively  has  resexed  her — a  statement  which  I  have 
made  about  a  number  of  other  cases  of  a  somewhat  similar 
kind. 

Two  cases  of  abscess  in  both  ovaries,  narrated  by  Mr.  C.  J. 
Cullingworth,  in  tlie  Lancet  of  November  3,  1877,  illustrate  well 
this  unusual  disease,  and  are  equally  instructive  in  showing  the 
disastrous  results  of  delay  in  the  performance  of  abdominal  sec- 
tion in  cases  of  doubt,  where  patients  are  suffering  from  pelvic 
mischief. 

The  first  was  a  case  of  a  woman,  aged  forty-five,  admitted  on 
January  13th,  with  vomiting,  severe  pain  in  and  enlargement  of 
the  abdomen.  In  the  lower  part  of  the  abdomen  was  a  fluctua- 
ting swelling,  reacliing  nearly  as  high  as  the  umbilicus,  quite 
dull  on  percussion,  and  a  soft,  rounded  swelling  in  the  vagina, 
to  the  right  of  the  uterus.  The  morning  temperature  was  low 
and  the  night  temperature  high,  showing  clearly  the  presence  of 
pus,  as  did  all  the  symptoms. 

"  January  27th. — Thirty-five  ounces  of  pus  were  withdrawn 
by  the  aspirator,  without  relief. 

"February  7th. — An  exploratory  incision  was  made,  and  a 


OOPHORITIS   AND    PERI-OOPJlOltlTIS — ABSCESS   OF   OVARY.    127 

large  abscess  opened  in  the  abdominal  walls,  outside  the  perito- 
neum, with  a  communication  into  the  abdominal  cavity.  The 
patient  died  a  few  hours  after  the  operation,  and  the  post-mortem 
displayed  that  the  source  of  the  mischief  was  an  abscess  in  the 
right  ovary,  which  had  burst.  The  left  ovary  also  had  become 
converted  into  a  small  bag  of  purulent  fluid."'  The  case  seems  to 
have  had  a  very  chronic  progress,  and  if  the  abdominal  section 
had  been  done  some  weeks  before  it  was,  there  probably  would 
have  been  a  successful  result. 

The  second  case  is  an  even  more  instructive  one.  About  the 
middle  of  1875  she  noticed  an  enlargement  of  the  abdomen,  and 
was  suffering  from  local  distress.  In  June,  187G,  this  amounted 
to  constant  pain  in  the  left  iliac  region,  where  there  was  a  dis- 
tinct, hard  swelling,  tender  on  pressure.  The  uterus  was  quite 
hard,  the  vagina  was  encroached  upon,  and  its  upper  part  ex- 
quisitely tender  to  the  slightest  touch,  causing  great  suffering. 
An  exploratory  puncture  was  made  without  result,  and  after 
some  months'  residence  in  the  hospital  she  was  discharged  on 
March  31,  1877. 

She  was  readmitted  in  May  following,  with  the  symptoms 
much  aggravated,  the  abdomen  uniformly  enlarged  and  univer- 
sally tender,  and  the  old,  tender  swelling  could  still  be  felt.  The 
night  temperature  was  always  considerably  higher  than  that  of 
the  morning.  She  was  kept  under  observation  till  August  3d, 
when  she  died. 

The  post-mortem  examination  revealed  old  peritonitis.  The 
right  ovary  was  four  and  three-fourths  inches  in  its  large  cir- 
cumference, and  three  and  one-fourth  in  its  shorter,  and  was  a 
mere  shell,  filled  with  offensive,  purulent  fluid.  The  left  ovary 
was  much  larger,  and  formed  the  large  tumor  which  was  felt 
during  life,  and  this  again  was  filled  with  a  highly  offensive, 
purulent  fluid. 

In  such  a  case  as  this  it  is  impossible  to  resist  the  conclusion 
that  abdominal  section,  performed  soon  after  the  onset  of  the  se- 
rious symptoms,  would  have  enabled  the  surgeon  to  have  re- 
lieved his  patient. 

M.  C.  Darolles  contributes  some  valuable  observations  con- 
cerning the  microscopic  examination  of  ovaries,  in  which  ovaritis 
had  resulted  in  the  formation  of  abscess.  He  found  that  the 
process  began  in  the  suppuration  of  separate  follicles,  and  that 
these  subsequently  coalesced,  forming  abscess  of  the  whole  gland. 
Such  cases,  he  points  out,  as  well  as  those  of  suppurative  inflam- 
mation of  the  tubes,  frequently  result  in  a  series  of  secondary 


128  DISEASES    OF   THE    OVAKIES, 

accidents,  such  as  pelvi-peritonitis  and  acute  general  peritonitis, 
which  may  have  a  rapidly  fatal  issue. 

M.  C.  Salamon  has  narrated  a  series  of  cases  of  tubercle  of 
the  ovary ;  but,  as  this  condition  is  always  associated  with  tuber- 
cle elsewhere,  which  is  of  far  greater  consequence,  it  can  be 
regarded  only  as  having  an  interest  of  curiosity.  I  have  not 
heard  of  a  case  of  tubercle  of  the  ovary  only. 

Hermaphroditism. — If  the  law  of  evolution  embraces  all  or- 
ganized structures  —  and  its  details  have  now  been  so  fully 
worked  out  that  Ave  may  assume  that  it  does — we  must  accept 
Darwin's  theory  of  the  descent  of  man.  This  acceptance  at  once 
becomes  the  explanation  of  the  occasional  occurrence  of  bisexual 
vertebrates,  and  consequently  of  true  hermaphroditism  in  human 
individuals.  Conversely,  the  occurrence  of  such  malformations 
may  be  offered  as  one  among  the  many  proofs  which  are  being 
accumulated  from  every  quarter  in  favor  of  Darwin's  theory,  for 
they  must  be  regarded  as  reversions  of  type.  In  the  vegetable 
kingdom  the  majority  of  the  species  are  bisexual,  though  inodern 
investigations  have  shown  most  ingenious  contrivances  to  secure 
the  advantages  of  cross-fertilization.'  Even  in  the  more  com- 
plex organisms  of  the  animal  kingdom,  bisexuality  is  met  with 
as  high  up  as  the  nudibranchiata,  while  in  the  next  sub-order, 
the  prosobranchiata,  most  of  the  groups  are  unisexual.  In  the 
cephalopoda,  where  other  great  advances  in  structure  are  indi- 
cated, unisexuality  is  the  rule.  From  this  point  a  symmetrically 
double  body  is  introduced  into  the  schema,  though  it  is  met  with 
also  in  the  inseeta,  and  the  sexual  organs  are  double,  one  in 
each  half  of  the  body.  But  as  in  the  inseeta,' where  unisexuality 
is  the  rule,  hermaphroditism  occurs  with  some  frequency,  so  it 
does  in  the  lower  vertebrates,  the  frequency  of  the  malforma- 
tion diminishing,  until  in  man  true  hermaphroditism  is  found 
very  rarely.  In  all  cases  of  hermaphroditism  in  animals  where 
unisexuality  of  the  individuals  is  the  rule,  the  doubly  sexed 
organs  are  always  imperfect,  even  in  insects  ;  and  in  most  of  the 
cases  recorded  in  birds  there  has  been  on  the  male  side  only  a 
convoluted  seminal  tube  and  no  testicle,  so  that  the  tube  might 
have  been  taken  for  an  aborted  oviduct,  had  it  not  been,  as  in 
one  of  Simpson's  cases  ("Encyclopaedia  of  Anatomy  and  Physi- 
ology "),  for  the  coincident  presence  of  the  characteristic  epithe- 
lial appendages  of  the  male.  In  Simpson's  second  case  I  do  not 
think  there  was  any  evidence  of  true  hermaphroditism. 


'  See  Darwin's  "  Fertilisation  of  Orchids,"  "Cross  and  Self-Fertilisation  of  Flowers,' 
and  Kerner's  ''  Flowers  and  their  Unbidden  Guests." 


OOPHORITIS    ATS'D   PERI-OOPIIORITIS — ABSCESS    OF   OVARY.    129 

The  human  testicle  and  ovary  being  developed  from  the  same 
blastema,  and  being  really  the  same  organ,  it  is  not  surprising 
that  occasionally  reversions  of  type  should  occur,  so  that  an  im- 
mature testicle  should  appear  on  the  one  side,  and  an  imperfect 
ovary  on  the  other.  According  to  Simpson,  the  ovary  in  these 
cases  appears  generally  on  the  left  side.  This  distinguished 
author  has  collected  from  many  sources  a  large  number  of  cases, 
the  descriptions  of  some  of  which  are  not  above  suspicion  ;  but 
in  others,  especially  that  recorded  by  Dr.  Banon  in  the  Dublin 
Medical  Journal  for  1852,  the  facts  are  beyond  dispute;  for  the 
examination  of  the  textures  of  the  gland  on  either  side  by  the 
microscope  completely  established  that  one  was  an  ovary  and 
that  the  other  was  a  testicle,  though  both  were  so  immature  as 
to  contain  no  perfect  products.  There  was  an  imperforate  penis, 
the  urethra  opening  at  its  root,  and  behind  this  a  genital  canal 
closed  by  a  perfect  crescentic  hymen,  a  fact  which  at  once 
removes  the  case  from  the  classes  of  spurious  hermaphrodites 
already  described.  This  genital  canal  led  up  to  a  small,  well- 
formed  uterus  with  normal  relations  to  the  bladder,  rectum,  and 
peritoneum,  and  having  at  its  left  cornu  a  perfect  Fallopian 
tube  with  a  corpus  fimbriatum.  In  relation  with  this  there  was 
an  ovary.  There  was  neither  tube  nor  ovary  on  the  right  side, 
but  a  testicle  containing  the  characteristic  tubules,  and  provided 
with  an  epidydimis  and  vas  deferens.  Simpson  calls  this  true 
lateral  hermaphroditism  ;  and  he  further  describes  what  he  calls 
true  transverse  hermaphroditism,  that  is,  where  the  internal 
organs,  testicles,  or  ovaries,  are  alike  on  the  two  sides,  but  the 
external  organs  represent  appearances  somewhat  like  those  of 
the  other  sex.  But  it  is  not  clear  in  any  of  the  cases  he  quotes 
that  the  malformation  was  anything  more  than  an  extension  of 
the  characters  of  spurious  hermaphroditism  ;  and  as  the  glan- 
dular element  must  always  be  considered  as  the  chief  element  of 
sex,  it  is  not  a  philosophical  proceeding  to  say  that  both  sexes 
are  represented  unless  both  a  testicle  and  an  ovary  are  present. 
Even  when  the  clitoris  is  perforated  by  a  urethra  as  far  as  the 
glans,  the  condition  is  only  that  seen  normally  in  the  Loris 
gracilis. 

This  view,  which  I  first  enunciated  in  1873,  has  been  most 
fully  confirmed  by  an  admirable  paper  by  Prof.  Morrison  Wat- 
son, in  the  Journal  of  Anatomy,  October,  1879.  He  says  :  "In 
the  gland  alone  and  its  structure  is  to  be  found  the  determina- 
tion of  sex.  No  arrangement  of  the  passage  is  absolutely  dis- 
tinctive. Even  the  prostate  gland  is  absent  in  the  males  of  some 
animals  (elk,  red  deer,  etc.),  and  it  is  occasionally  present  in 
many  female  mammals,  even  women.  The  lateral  hermaphro- 
9 


130  DISEASES   OF  THE   OVARIES. 

dites  of  Simpson  are  those  to  whom  alone  the  terra  frwe  can  be 
applied." 

In  Simpson's  third  variety,  to  which  he  gives  the  name  of 
'•true  double  or  vertical  hermaphroditism,"  he  describes  the 
presence  of  a  gland  of  each  sex  as  present  on  both  sides,  or,  as 
he  says,  "  actual  sexual  duplicity."  Without  denying  the  possi- 
bility of  such  an  occurrence,  I  must  say  that  I  think  it  very  un- 
likely, and  I  have  no  hesitation  in  saying  that  none  of  the  cases 
he  quotes  justifies  the  establishment  of  this  variety.  The  most 
complete  case  is  that  recorded  by  Vrolik,  and  he  distinctly  states 
that  neither  in  the  structure  which  he  supposed  to  be  testicle  nor 
in  that  considered  to  be  ovary  did  he  find  a  trace  of  histological 
evidence  of 'the  nature  of  the  gland.  Mere  anatomical  position 
goes  for  nothing  in  such  a  case,  for  the  ovary  descends  some- 
times in  the  same  way  as  does  the  testicle,  for  it  also  has  a 
gubernaculum.  It  must  also  be  borne  in  mind  that  occasionally 
appendices  both  to  testicle  and  ovary  are  met  with,  giving  the 
appearance  as  if  the  individual  had  three  or  even  four  testicles 
or  ovaries.  If  such  a  condition  were  met  with  in  a  hypospadic 
male  who  had  at  the  same  time  an  enlarged  prostatic  utriculus, 
as  many  of  the  cases  quoted  by  Simpson  undoubtedly  had,  and 
if  the  testicular  appendix  had  not  descended  with  the  true  testicle, 
the  appearances  would  be  exactly  as  described  in  most  of  Simp- 
son's cases,  and  yet  there  would  be  not  the  slightest  reason  for 
the  statement  that  both  kinds  of  glands  were  present.  The  only 
satisfactory  test  is  that  of  microscopic  examination;  and  so  far 
the  evidence  goes  to  show  that  there  is  only  one  kind  of  true 
hermaphroditism— that  in  which  there  is  an  ovary  on  the  one  side 
and  a  testicle  on  the  other. 

The  cases  lately  recorded  by  Leopold,  of  Leipsic,  and  C.  E. 
Underbill,  of  Edinburgh,  are  clearly  cases  of  descent  of  undevel- 
oped ovaries  into  the  inguinal  canal — instances  of  hypererchesis. 


CHAPTER  lY. 

OVAEIAN  TUMOES   AND   CONDITIONS  WHICH   SIMULATE   THEM. 

Billroth's  Handbuch  der  Frauenkrankheiten.     Heft  VI.     R.  Olshausen.     Stuttgart, 

1877. 
Clinical  Lectures.     Mathews  Duncan.     London,  1879. 
Gooch  on  Diseases  of  Women.     Fergusson.     London,  1859. 
Kystes  de  I'ovaire.     Gallez.     Bruxelles,  1873. 
Ovarian  Tumours.     Peaslek.     London,  1873. 
Diseases  of  the  Abdomen.     Edward  Ballard.     London,  1853. 
Ovarian  Physiology  and  Pathology.     Eitchie.     London,  1865. 
Lessons  in  Gynecology.     Goodell.     Philadelphia,  1880. 
Females  and  their  Diseases.     Meigs.     Philadelphia,  1848. 
Ovarian  Tumors.     Atlee.     Philadelphia,  1873. 
Ovarian  Dropsy.     Baker  Brown.     London,  1868. 
Tumours  of  the  Uterus.     T.  S.  Lee.     London,  1847. 
Entwickelung  der  Ovariencysten.     Stahl.     Cent.  f.  Gyn.,  V.,  I. 
.^tiologie  der  Ovariencysten.     Breisky.     Cent.  f.  Gyn.,  V.,  I. 
Ovariencarcinom.     Ullac.     Cent.  f.  Gyn.,  V.,  I. 
Myxoid  Krebs  der  Ovarien.     Mosse.     Cent.  f.  Gyn.,  V.,  I. 
Ovarienschwangerschaft  (Spiegelberg).     GURCHARD.     Cent.  f.  Gyn.,  V.,  I. 
Grossesse  de  I'ovaire.     Puech.     Ann.  de  Gyn. ,  July,  1878. 
Ovarienadenom.     Neelsen.     Cent.  f.  Gyn.,  V.,  IIL 
Eierstocksarcomen.     Leopold.     Arch.  f.  Gyn.,  V.,  XIII. 

Ueber  Blutergiisse  u.  Blutgeschwulste  der  Ovarien.     Leopold.    Arch.  f.  G.,  V.,  XIII. 
Ovarium  Tumor  mit  elweissfreien  Inhalte.    Westpetal.    Schmidt's  Jahrbuch,  V.  169. 
Ovarium  Cystenadenosarkom.     Schmidt.     V.  174. 
Ovarialschwangerschaft.     Schmiedt.     Schmidt.  V.  178. 

Carcinom  der  Ovarien.     KiJSTER  u.  Kegscheider.     Beitriige  f.  Geburt.    V.  4. 
Ueber  Dermoid-Cysten  des  Ovariums.     Pauly.     B.  f.  Geb.    V.  4. 
Ovarialschwangerschaft.     Besuche.     Berlin,  1876. 
Histologie  der  Ovarientumoren.     Marchand.     Cent.  f.  Chir.     V.  4. 
Cavernoses  Fibrom  des  linken  Ovarium.     Dannier.     Arch.  f.  Chir.     V.  21. 
Ein  Fall  von  Psammocarcinom  des  Ovarium.     Flaischlen.     Virchow'a  Arch. ,  Jan. , 

1880. 
Des  Tumeurs  solides  de  I'ovaire.     Liembecki.     Arch,  de  Gyn.,  1877. 
Ovarian  Cysts  in  Infants.     Leared.     Lancet,  1878,  VI. 
Fibroma  of  the  Ovaries.     Goodhart.     Med.  T.  and  Gaz.,  1874. 
Ovarian  Cyst  with  Muscular  Envelope.     G.  Hewitt,     Patholog.  Soc.  Trans.,  1874. 
Pathology  of  the  Ovaries.     M.  Duncan.     Med.  T.  and  Gaz.,  1875. 
Dermoid  Tumours  of  the  Ovaries.     Med.  T.  and  Gaz..  1877. 
Tumours  of  the  Ovary  in  the  Pheasant.     Slater.     J.  Anat.  and  Phys.,  1879. 


132  DISEASES   OF   THE   OVARIES. 

Kystes  de  Tovaire.     Sinety  and  Melassez.     Arcli.  de  Phys.,  1878. 

Ovarian  Serous  Cysts.     Panas.     Amer.  J.  Obstet.,  May,  1875. 

Ovarian  and  Parovarian  Cysts.     Koeberle.     Obstet.  Journ.     V.  4. 

Cancer  of  Ovary.     FouLis.     Ed.  Med.  Jour.,  1874-75. 

Pathology  of  Unilocular  Ovarian  Cysts.     Bantock. 

Suppurating  Ovarian  Cysts.     Keith.     Edin.  Med.  Journal. 

Torsion  of  Pedicle  of  Ovary.     Koeberle.     Amer.  Med.  J.  Obstet.,  1878. 

Axial  Rotation  of  Ovarian  Tumours.     Lawson  Tait.     Trans.  Obstet.  Soo.  Lend.  Vol. 

XXII. 
Maladies  des  Ovaires.     Boinet.     Arch.  Generales.     1874. 
Cancer  of  Ovaries  Transplanted.     GooDnART.     Pathol.  Trans.,  1874. 
Fibro  cystic  Disease  of  Ovaries.     Legg.     Pathol.  Trans.,  1874. 
Fibroma  of  Ovaries.     Goodhart.     Pathol.  Trans.,  1874. 
Fibroma  of  Ovaries.     Walsham.     Pathol.  Trans.,  1876. 
Fibroid  Ovaries.     Crisp.     Pathol.  Trans.,  1877. 
Lymphadenoma  of  Ovaries.     Co  upland.     Pathol.  Trans  ,  1877. 
Intra-ovarian  Pregnancy.     Talbot.     Med.  Record,  1879. 
Ovarian  Pregnancy.     Med.  Record,  1874. 
Extra-Uterine  Gestation  of  the  Tubo-Ovarian  Form.     Dr.  Siblet  Campbell.    Amer. 

Jour.  Obstet.,  Vol.  1870. 
Eierstocksschwangerschaft.     Leopold  L.\ndau.     Arshiv.  f.  Gyniikologie,  Bd.  XVI. 
P jpilloma  of  Ovary.      Emmet.     New  York  Med.  Journal,  1879. 
Diagnosis  of  Ovarian  Tumors.     Boston  Med.  J.,  1879. 
Zur  normalen  und  pathologischen  Histologic  des  Graaf'schen  Blaschens  des  Menschen. 

SwiANSKL     Virchow's  Arch.     V.  51. 
Rokitansky's  Pathological  Anatomy.     Sydenham  Society. 

Pathologische  Anatomic  der  weiblichen  Sexual -Organe.     Klob.     Vienna,  1864. 
Beobachtungen  ilber  die  Entwickelung  multilocalaren  Eierstockcysten.     Boettciier. 

Virchow's  Archives.      V.  XLIX. 
On  Cystic  Tumours  of  the  Ovary.    Wilson  Fox.     Trans.  Roy.  Med.-Chir.  Soc,  1864. 

Ovarian  pathology  has  always  been  a  fertile  field  for  re- 
search, and  although  the  list  of  writers  upon  this  subject  which 
I  have  given  above  is  a  long  one,  it  by  no  means  fully  represents 
the  great  number  of  contributions  which  have  been  given  to  it. 
The  interest  which  diseases  of  these  organs  has  always  excited 
has  been  greatly  increased  during  the  last  twenty  years,  owing 
to  the  remarkable  triumphs  which  surgery  has  achieved  in  the 
establishment  of  ovariotomy  as  the  most  successful  of  the  major 
operations. 

The  pathology  of  ovarian  tumors — especially  those  of  a  cystic 
character — involves  a  number  of  questions  which  have  been 
raised  and  discussed  by  observers  of  the  greatest  eminence;  but 
I  think  it  is  only  in  very  recent  times  that  anything  like  a  rea- 
sonable view  of  the  origin  of  these  growths  has  been  advanced. 
In  the  first  edition  of  this  book  I  said  that,  up  to  the  time  of  my 
writing  it,  I  had  found  very  little  which  either  harmonized  with 
my  own  observations,  or  seemed  to  me  to  give  any  satisfactory 
explanation  of  these  growths.  The  conclusions  which  I  put  for- 
ward were  at  variance  with  those  held  by  many  previous  and 


OVARIAl^  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      133 

probably  much  more  competent  observers;  but  these  conclusions 
nevertheless  seemed  to  me  to  be  founded  on  fact,  and  to  have 
the  strong  recommendation  of  affording  explanations  which 
were  at  least  simple  and  intelligible.  Since  I  wrote  this  a  good 
deal  more  has  appeared  on  the  subject,  much  of  which  I  have 
carefully  studied,  but  without  finding  reason  to  depart  from  the 
views  I  published  in  1873. 

What  seem  to  me  by  far  the  most  important  contributions 
recently  made  to  ovarian  pathology  are  the  papers  published  by 
MM.  De  Sinety  and  Melassez,  in  the  Archives  de  Physiologie  for 
1878.  I  find  in  these  papers  a  great  deal  which  completely  con- 
firms my  own  previous  conclusions;  but,  on  the  other  hand,  it  is 
equally  fair  to  say  that  much  which  has  been  advanced  by  these 
authors  is  quite  out  of  harmony  with  what  I  have  myself  ob- 
served. Upon  the  latter  point,  however,  I  think  the  facts  estab- 
lished by  Balfour,  in  his  researches  upon  the  development  of  the 
ovary,  which  have  been  given  at  length  in  a  preceding  chapter, 
may  be  taken  as  conclusive,  more  particularly  upon  the  alleged 
development  of  cystic  disease  of  the  ovary  from  the  so-called 
tubes  of  Pfliiger. 

As  to  the  prime  causes  which  lead  to  any  of  these  diseases, 
we  may  at  once  confess  ourselves  to  be  profoundly  ignorant,  and 
what  little  we  do  know  is  entirely  confined  to  the  processes  by 
which  these  causes  produce  their  peculiar  results.  It  may  be 
that  some  day  we  shall  know  here,  as  we  desire  so  much  to  know 
in  every  other  field  of  pathological  inquiry,  what  may  be  the  ul- 
timate causes  of  any  particular  lesion;  but  up  to  the  present  we 
have  no  instance  of  any  knowledge  of  this  kind. 

It  is  extremely  difficult  to  arrange  the  discussion  of  this  sub- 
ject in  such  an  order  as  will  be  satisfactory  from  a  general  view, 
and  any  division  of  ovarian  tumors  must  be  entirely  arbitrary. 
We  may  take  them  from  their  physical  characteristics,  or  from 
their  surgical  peculiarities,  or  from  their  microscopic  appear- 
ances, or  from  their  supposed  methods  of  origin,  but  we  cannot 
possibly  take  them  in  an  order  which  will  satisfy  all  these  as- 
pects. De  Sinety  and  Melassez  adopt  a  perfectly  arbitrary 
method  of  classification,  which  in  itself  would  not  be  objection- 
able were  it  not  that  the  names  they  make  use  of  for  the  pur- 
poses of  their  division  are  such  as — in  England  at  least — involve 
certain  meanings  which  the  authors  evidently  do  not  imply  by 
them.  Thus,  they  divide  their  observations  into  those  upon 
"  cystic  ovaries,"  thereby  meaning  instances  where  the  cysts  are 
very  small,  and  where  the  ovary  is  still  easily  recognizable. 
"Cysts  of  the  ovary"  they  use  to  designate  tumors  where  the 
ovary  is  no  longer  distinct,  but  seems  to  have  disappeared.    And 


134  DISEASES   OF   THE   OVARIES. 

then  again,  when  they  speak  of  a  case  in  which  the  solid  parts 
of  a  tumor  become  the  predominant  elements,  they  use  the  term 
"  cystic  tumor."  It  is  perfectly  useless  to  take  up  space  in  dis- 
cussing the  want  of  precision  of  such  a  division  as  this;  all  that 
can  be  said  in  its  favor  is  that  it  is  no  more  illogical  than  others 
which  have  been  propounded.  The  authors  themselves  say:  "  It 
is  very  certain  that  between  cystic  ovaries,  ovarian  cysts,  and 
cystic  tumors  of  the  ovary,  there  exists  quite  a  series  of  interme- 
diate tumors,  and  that  it  would  be  very  difficult,  even  impossible, 
to  establish  between  them  well-defined  lines  of  demarcation.  In 
fact,  the  difficulty  is  just  the  same  as  has  been  found,  within 
the  last  two  or  three  years,  to  hang  round  the  use  of  the  word 
ovariotomy  ;  for  every  one  whose  experience  has  extended  be- 
yond the  removal  of  large  ovarian  cystomata,  has  found  it  quite 
impossible  to  use  any  such  word  as  oophorectomy,  in  contradis- 
tinction to  ovariotomy,  without  some  arbitrary  definition  and 
division  of  his  cases.  Therefore  I  have  already  indicated  my 
intention  hereafter  to  make  use  of  the  word  ovariotomy  to  in- 
clude the  removal  of  an  ovary  for  any  purpose  or  disease  what- 
soever. In  like  manner  I  intend  the  word  cystoma  to  refer  to 
any  disease  of  the  ovary  in  which  the  existence  of  cysts  is  a 
leading  characteristic.  Whether  I  may  be  more  successful  than 
my  predecessors  in  establishing  subdivisions  of  this  disease,  or 
whether  I  may  succeed  in  giving  a  rational  view  of  their  meth- 
ods of  production,  must  be  left  to  the  judgment  of  my  readers. 

In  the  first  chapter  of  this  book  I  have  drawn  attention  to  the 
somewhat  numerous  observations  which  establish  the  fact  that 
at  the  time  of  birth  the  follicles  of  the  ovary  are  very  frequently 
found  to  be  so  much  distended  by  limpid  fluid  as  almost  to  pre- 
sent the  appearances  of  disease;  and  from  the  fact,  equally  well 
established,  that  these  cysts  do  rupture  and  go  through  the  stages 
of  cicatrization,  we  may  assume  as  proved,  that  in  the  dropsical 
distention  of  the  Graafian  follicle  we  have  at  least  a  very  com- 
mon origin  of  ovarian  cystoma.  If  we  go  through  the  literature 
of  this  subject,  we  shall  find  numerous  instances  in  Avhich  these 
follicles  have  become  so  distended  as  to  have  an  absolutely  morbid 
appearance.  Thus,  in  the  American  Journal  of  Obstetrics  for 
January,  1880,  Dr.  T.  G.  Thomas  describes  an  ovarian  cyst,  re- 
moved post-mortem  from  a  new-born  child,  which  was  sent 
him  by  a  physician  in  New  Jersey.  The  peculiarity  in  the  case 
was  that  the  child  was  delivered  at  full  term,  and  nothing  ab- 
normal was  discovered.  About  one  month  after  birth  a  tumor 
was  discovered  in  one  iliac  fossa,  about  the  size  of  a  hen's  Q^g. 
The  child  was  well  developed  at  the  birth,  but  soon  began  to 
show  signs  of  impaired  nutrition,  grew  very  slowly,  became 


OVARIAN  TUMOllS,   CONDITIONS  WHICH  SIMULATE  TIIEM.      135 

emaciated,  and  languished  until  it  was  three  years  and  five 
months  old,  and  then  died.  The  autopsy  revealed  the  existence 
of  an  ordinary  ovarian  (or  parovarian  ?)  cyst  filling  the  abdomen. 
The  remains  of  the  Fallopian  tube  and  ovary  were  upon  one  side 
of  the  tumor. 

At  a  meeting  of  the  Pathological  Society  of  London,  on  May 
21,  1878,  Dr.  Leared  showed  specimens  of  ovarian  cysts  from 
twin  infants,  who  had  been  under  the  care  of  Dr.  Macmahon,  of 
Norwood.  They  were  born  at  full  term,  and  one,  jaundiced 
from  birth,  died  at  the  age  of  eight  weeks.  There  v/as  found 
complete  obliteration  of  the  common  bile-duct.  Each  ovary  was 
the  seat  of  a  cyst  the  size  of  a  filbert.  The  other  child  died  from 
pneumonia,  and  it  also  presented  a  small  ovarian  cyst  the  size  of 
a  pea. 

The  observations  of  De  Sinety  and  Melassez,  and  also  those  of 
Hausmann,  therefore,  lead  us  to  the  conclusion — which  has  been 
quite  established  by  fact — that  ovarian  cystoma  may  be  the  result 
of  these  processes  in  the  young  child,  and  that  we  may  expect, 
every  now  and  then,  to  see  one  of  these  follicular  dropsies  reach 
such  a  size  as  to  require  surgical  interference.  Thus,  Dr.  Basil, 
of  Bonn,  has  performed  ovariotomy  on  a  child  two  years  of  age, 
on  account  of  a  large  cystoma.  Mr.  Folker,  of  Hanley,  has  op- 
erated at  three  years  of  age.  A  case  is  recorded  by  some  Ameri- 
can surgeon  of  an  operation  at  seven,  and  Mr.  Wells  has  operated 
on  a  child  of  eight  years.  The  probability  is  that  in  these  cases, 
and  in  many  others,  the  cystoma  has  been  due  to  the  extension 
of  the  follicular  dropsy,  which  occurs  normally  during  the  first 
three  months  of  life,  and  which  has  become  pathological  by  rea- 
son of  the  follicles  not  rupturing,  as  in  the  ordinary  course  of 
events. 

Waldeyer,  in  the  Arch.  f.  Gyncekologie,  tome  I.,  p.  289,  also 
observes  that:  "In  the  ovaries  of  old  women  are  often  found 
small  cysts  from  the  size  of  a  pea.  .  .  .  They  are  covered  with  a 
cylindrical  epithelium,  which,  under  the  form  of  glandular  tubes, 
often  penetrates  into  the  ovarian  stroma.  .  .  .  These  little  cysto- 
mata  never  contain  ovules  or  remains  of  ovules,  ...  In  some 
cases  may  be  seen  a  continuation  of  the  epithelium  which  covers 
these  cystic  cavities  with  the  epithelium  of  the  ovarian  surface." 

Here,  then,  we  have  a  starting-point,  from  which  we  may 
arrive  at  an  explanation  of  ovarian  cystoma — the  only  one,  in 
my  belief,  that  can  be  reasonably  advanced.  It  seems  to  me  it 
will  explain  all  the  specimens  which  I  myself  have  examined. 
Indeed,  I  am  quite  strengthened  by  my  later  researches,  as  well 
as  by  those  before  referred  to,  in  the  views  I  advanced  eight 
years  ago,  to  the  effect  that  ovarian  cystoma  is  the  result  of  f ol- 


136  DISEASES   OF   THE   OVARIES. 

licular  dropsy  only.  The  fact  which  is  now  almost  universally 
admitted,  that  ovarian  cystomata  are  never  unilocular,  also 
points  to  this  conclusion.  Thus,  De  Sinety  and  Melassez  say: 
"■  Amongst  all  the  cysts  we  have  examined,  we  have  not  found 
one  which  was  truly  unilocular.  All  those  sent  to  us  as  such 
presented,  truly,  a  large  principal  cyst,  but,  on  examining  them 
with  care,  we  have  always  found  other  cystic  cavities,  some- 
times small  enough,  it  is  true,  to  pass  unperceived  on  a  first 
examination."' 

This  conclusion  I  can  entirely  substantiate  from  the  exam- 
ination of  a  very  large  number  of  tumors.  There  is  one  possible 
exception,  however,  and  that  is  of  a  small  cyst — now  in  the  mu- 
seum of  the  College  of  Surgeons — which  I  removed  as  an  ovary, 
in  a  case  of  severe  hemorrhage  due  to  a  uterine  myoma.  The 
patient  recovered,  and  the  operation  had  for  some  months  a  per- 
fectly successful  result;  but  about  seven  months  after  it  she  died, 
as  I  believe,  from  cancer  of  the  uterus.  No  post-mortem  exam- 
ination was  made,  and  I  have  been  quite  unable  to  obtain  any 
information  concerning  her  case  from  the  practitioner  under 
whose  care  she  was  at  the  time  of  her  death.  It  is,  therefore 
quite  possible  that  what  I  removed  on  that  side  was  not  the 
ovary;  or,  it  may  be  that  I  did  not  remove  the  whole  of  the 
ovary,  but  merely  an  outstanding  cyst.  At  any  rate,  I  do  not 
feel  disposed,  on  account  of  this  isolated  and  incomplete  obser- 
vation, to  depart  from  the  conclusion  I  have  come  to  from  an 
otherwise  uniform  experience,  which  is  that  such  a  thing  as  a 
unilocular  ovarian  cystoma  does  not  occur.  On  a  priori  grounds 
such  a  condition  would  be  extremely  unlikely,  for  it  is  difficult  to 
imagine — whatever  be  the  cause  of  the  distention  of  Graafian 
follicles  into  pathological  cysts — that  it  could  or  would  affect  one 
follicle  only,  and  allow  the  rest  of  the  gland  to  remain  free  from 
its  influence.  Conversely,  granting  the  likelihood  that  follicular 
dropsy  develops  ovarian  cystoma,  then  we  have  at  once  an  ex- 
planation of  what  is  the  fact — that  these  tumors  are  always  mul- 
tilocular. 

I  think  that  the  term  adenoid  may  be  retained  with  advan- 
tage in  the  nomenclature  of  ovarian  tumors,  because  it  con- 
veniently classes  them  with  reference  to  the  tissue  from  which 
they  originate,  and  by  the  hyperplasia  of  which  they  are  formed, 
without  giving  any  theoretical  explanation  of  their  formation. 
All  non-cancerous  tumors  of  the  ovary  are,  therefore,  adenoid; 
even  the  dermoid  tumors  are  so  to  a  certain  extent,  for  they  are 
the  result  of  increased  growth  of  one  or  other  normal  constituent 
of  the  gland,  without  alteration  save  in  quantity.  Cancerous 
growths,  on  the  other  hand,  introduce  tissue  which  is  either  not 


OVARIAN  TUMORS,   CONDITIONS  WHICH  SIMULATE  TIIEM.      137 

found  in  the  gland  normally,  or  they  produce  it  in  a  form  which 
is  immature. 

There  are  two  methods  of  origin  for  pathological  cysts  which 
are  universally  accepted,  and  both  of  which  are  instanced  in  the 
ovary.  The  first  is  by  occlusion  of  normal  ducts  or  tubes,  as  best 
seen,  perhaps,  in  the  kidney  and  salivary  glands,  and  in  connec- 
tion with  the  ovary  in  the  form  of  cystic  dilatation  of  the  Fallo- 
pian tube  or  of  its  trumpet-shaped  extremity,  after  adhesion  to 
the  ovary — tubal  and  tubo-ovarian  cysts.  The  other  form  of 
cyst-growth  consists  in  the  dilatation  of  a  physiological  cyst- 
cavity  by  its  own  secretion  poured  out  to  an  abnormal  extent; 
and  this  secretion  may  either  retain  its  original  character  and 
constitution,  or  be  altered  by  the  addition  of  blood  or  of  some  of 
its  usual  or  exceptional  albuminous  products.  This  is  the  com- 
mon form  of  cyst-formation  in  the  ovary,  and  in  the  multiple 
adenoid  tumor  and  in  the  dermoid  we  see  instances  of  it.  The 
former  illustrates  the  formation  of  cysts  by  the  retention  of  its 
products  in  the  cavity  of  the  normal  sac  of  the  gland,  these  pro- 
ducts being  the  fluid  cell-substance  and  its  nucleus,  the  ovum. 
This  is  accomplished,  as  far  as  I  could  discover  from  two  speci- 
mens I  have  to  describe,  by  hypertrophy  of  the  fibrous  covering 
of  the  gland — a  sclerosis  of  the  ovary  ;  and  the  nucleus,  the 
ovum,  seems  to  have  retained  its  normal  appearance  until  de- 
stroyed by  some  process  not  yet  understood.  It  is,  however, 
possible  that  some  defect  of  action  in  the  nucleus  may  have  to 
do  with  the  non-rupture  of  the  sac;  for,  under  healthy  conditions, 
it  is  undoubtedly  the  maturation  of  this  nucleus  that  governs  the 
rupture  of  the  wall  of  the  ovisac,  and  enables  the  perfect  ovum 
to  escape.  Upon  this  point  it  seems  to  me  that  the  observa- 
tions of  De  Sinety  and  Melassez  have  very  great  value,  for  they 
show  that,  coincident  with  the  absence  of  the  ovum  in  the  follicle, 
changes  are  effected  in  the  epithelium  of  a  very  marked  kind. 
Whether  they  result  from  or  are  themselves  the  cause  of  absence 
of  the  ovum,  we  cannot  say. 

The  dermoid  cysts  are  due,  on  the  other  hand,  to  an  altered 
and  increased  activity  of  the  cell-nucleus  in  early  life,  the  results 
remaining  latent  for  years,  until  re-excited  by  the  great  systemic 
change.  We  may  look,  then,  to  some  other  altered  condition  of 
the  cell-elements  for  explanation  of  the  remaining  variety  of 
cystic  tumor  of  the  ovary  which  has  been  termed  by  Mr.  Wells 
and  others  "  proliferous." 

I  do  not  like  this  term  as  applied  to  the  compound  cysts  of  any 
kind,  for  it  assumes,  what  I  am  quite  certain  is  not  true,  that  the 
larg-e  cysts  are  directly  the  parent  of  the  small  ones.  Thus,  Mr. 
Wells,  at  page  35  of  his  book  on  "  Diseases  of  the  Ovaries,"  de- 


138  DISEASES   OF   THE   OVARIES. 

fines:  ''Proliferous  cysts  —  parent-cysts  with  secondary  cysts 
growing  from  the  interior  of  the  cyst-wall."  These  minor  cysts 
are  secondary,  as  far  as  date  of  growth  is  concerned;  but  they 
are  the  younger  brothers  and  sisters,  not  the  children,  of  the 
larger  sacs.  In  fact,  the  very  caution  which  Paget  gave  his 
hearers  in  using  the  term  proliferous  is  disregarded  in  such  an 
application  of  it,  as  may  be  seen  from  the  following  quotation  : 

"In  an  ovary,  it  is  not  unfrequent  to  find  many  small  cysts, 
formed  apparently  by  the  coincident  enlargement  of  separate 
Graafian  vesicles.  These  lie  close  and  mutually  compressed, 
and,  as  they  all  enlarge  together,  and  sometimes,  by  the  wast- 
ing of  their  partition-walls,  come  into  communication,  they  may 
at  length  look  like  a  single  many-chambered  cyst,  having  its  one 
proper  wall  formed  by  the  extended  fibrous  covering  of  the 
ovary.  Many  multilocular  cysts,  as  they  are  named,  are  only 
groups  of  close-packed  single  cysts;  though,  when  examined  in 
late  periods  of  their  growth,  and  especially  when  one  of  the 
groups  of  cysts  enlarges  much  more  than  the  rest,  it  may  be 
difficult  to  distinguish  them  from  some  of  the  proliferous  cysts." 
(Paget's  "Surgical  Pathology,"  p.  415.) 

The  formation  of  a  compound  cystic  tumor  in  the  ovary, 
whether  it  be  of  the  multiple  variety  or  of  the  less  complete  kind 
of  which  I  am  about  to  speak,  may  be  very  well  illustrated  by 
blowing  soap-bubbles  in  a  basin.  If  the  fluid  be  not  viscid 
enough  to  enable  the  bells  to  retain  their  form,  then  the  normal 
condition  of  the  ovary  is  represented,  its  cells  bursting  and  dis- 
appearing. Let  us  suppose  that  the  cell-growth  is  constantly 
going  on,  and  that  some  alteration  occurs  in  the  state  of  matters 
which  prevents  the  cell- walls  bursting;  the  fluid  in  the  basin  is 
so  viscid  that  the  bells  do  not  break,  and  bubble  after  bubble  is 
formed,  some  larger,  some  smaller,  until  a  large  multicystic 
tumor  is  the  result.  The  actual  appearances  of  the  cystic  ovary 
may  be  very  well  imitated  in  the  basin  of  soap-lees,  A  large 
cyst  can  be  made  with  little  ones  crowding  into  it,  looking  like 
its  offspring,  and  the  walls  between  two  or  three  may  be  broken 
down,  making  one  larger  multilocular — the  remains  of  the  inter- 
vening walls  not  being  left  in  the  instance  of  the  soap-bubbles. 
If  they  had  been  left,  the  appearances  would  be  identical  with 
what  is  represented  diagrammatically  for  ovarian  tumors  in  Mr, 
Wells's  book  on  page  39,  In  the  ovary  we  have  the  continual 
production  of  cells,  representing  the  continuous  blowing  of  the 
bubbles;  and  we  have  only  to  discover  what  it  is  that  is  analo- 
gous in  the  ovary  to  the  increased  viscidity  in  the  solution  of 
soap ;  what  it  is  that  keeps  the  cysts  in  their  entirety,  pervert- 
ing a  physiological  into  a  pathological  process. 


OVAEIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      133 

With  the  exception  of  two  examples  of  "  Rokitansky's  tu- 
mor "  (to  which  I  give  the  name  of  multiple  cystoma),  and 
which  I  shall  afterward,  describe  at  length,  I  have  failed  to  find 
anything  like  ova  in  any  cysts  of  the  tumors  I  have  examined ; 
and  I  have  not  seen  any  reason  to  believe  that  the  little  second- 
ary cysts  met  with  in  the  walls  of  some  of  the  larger  sacs  are 
what  Dr.  Ritchie  has  interpreted  them  to  be — dropsy  of  the  blas- 
todermic vesicles  —  chiefly  because  I  have  failed  to  see  round 
them  anything  like  remains  of  the  membrana  granulosa,  and  I 
have  seen  three  or  four  of  them  on  more  than  one  occasion  on 
the  wall  of  the  same  sac.  In  searching  for  ova  in  the  cysts  of 
the  two  tumors  where  I  found  them,  I  had  seldom  occasion  to 
look  for  them  in  the  walls  of  the  cysts,  as  they  seemed  to  have 
been  floating  about  loose,  or  to  have  been  set  free  by  the  opening 
of  the  sacs.  In  other  cases,  not  finding  them  in  the  liquor  fol- 
liculi,  I  adopted  the  further  plan  of  first  isolating  the  cyst  to  be 
examined,  and,  having  opened  it,  I  searched  carefully  in  every 
sediment  of  its  contents  for  the  ovum.  Not  finding  it,  I  turned 
the  sac  inside  out  over  a  ball  of  cotton-wool  soaked  in  glycerine, 
smeared  its  everted  surface  with  the  same  substance,  and,  cover- 
ing it  piecemeal  with  a  thin  glass,  I  carefully  examined  it  over 
its  whole  extent  by  reflected  light.  I  never  found  anything  I 
thought  was  an  ovum.  In  one  tumor  which  I  removed  lately,  I 
found  a  mass  of  secondary  growth  in  the  position  of  the  ovary  at 
the  base  of  a  single  large  cyst.  I  made  sections  of  this  mass  by 
the  freezing  process,  and  found  it  composed  of  follicles  all  lined 
with  their  proper  epithelium  and  undergoing  cystic  enlargement, 
but  in  none  was  there  any  trace  of  an  ovum. 

I  cannot  reconcile  this  discrepancy  between  my  observations 
and  those  of  Dr.  Kitchie  otherwise  than  by  supposing  that,  hav- 
ing been  one  of  the  discoverers  of  ova  in  a  certain  kind  of  ovarian 
tumor,  he  was  too  anxious  to  apply  his  principle  of  explanation 
to  all;  or  he  must  have  had  a  plan  of  examination  more  success- 
ful than  mine. 

My  original  observations,  made  in  1872,  have  been  amply 
confirmed  by  De  Sinety  and  Melassez,  who  say:  "  no  author  has 
met  with  ovules  in  cysts  larger  than  a  walnut.  All  the  large 
cysts  we  have  studied,  and  which  we  shall  describe  farther  on, 
possessed  an  epithelial  investment  completely  different  from 
that  of  the  follicles,  a  fact  equally  attested  by  all  recent  observ- 
ers." Rindfleisch  has  found,  only  once,  one  ovule  in  an  ovarian 
cyst  of  which  the  cavity  was  no  larger  than  a  cherry. 

The  fact  that  I  never  found  ova  in  any  of  the  sacs  of  these  mul- 
ticystic  tumors,  even  the  smallest,  or  in  those  with  the  most  lim- 
pid contents,  led  me  to  entertain  the  opinion  that  in  this  we  have 


140  DISEASES    OF   THE    OVAlilES. 

an  explanation  of  their  formation.  The  function  of  the  ovary  is 
one  of  cyst-formation  from  its  earliest  existence  to  its  latest,  and 
in  its  pathology  we  need  not  go  far  away  from  its  physiology. 
It  seems  to  me,  therefore,  a  piHori,  very  unnecessary  to  resort 
to  the  ingenious  explanations  of  cyst-formation  advanced  by 
Dr.  Wilson  Fox,  though  they  may  be  fitted  to  exceptional  cases. 
Experience  in  the  examination  of  the  growths  themselves  has 
strengthened  this  view;  for  my  wonder  is  greater,  the  more  I  sec 
of  them,  that  they  do  not  occur  more  commonly  and  with  more 
complexity  than  they  do,  considering  the  apparently  reckless 
amount  of  ovarian  cyst-production  that  goes  on  throughout  life. 

The  aim  and  object  of  this  cyst-formation  is  the  production, 
maturation,  and  discharge  of  the  ovum.  But,  if  the  ovum  be  not 
formed,  or  if  it  be  produced  only  to  a  rudimental  extent,  may  it 
not  happen  that  the  cyst  will  not  be  ruptured,  but  go  on  aim- 
lessly expanding  ?  Whatever  be  the  source  of  the  change,  wo 
know  that  it  does  not  affect  one  ovisac  alone,  but  may  influ- 
ence them  in  great  numbers,  whether  it  be  in  a  tumor  where 
the  ova  have  been  matured  and  subsequently  prevented  from 
escaping  by  sclerosis  of  the  coat  of  the  ovisac,  or  in  a  growth 
Avhere  the  ova  are  not  to  be  found.  There  is  a  great  clinical  dif- 
ference between  these  two  kinds  of  tumor;  for  in  the  one  the 
growth  is  very  limited  and  slow,  and  in  the  other  it  may  be,  and 
often  is,  extremely  rapid,  and  is  practically  unlimited  in  extent. 
In  fact,  the  growth  of  these  cysts  without  ova  partakes  some- 
what of  the  character  of  malignancy  assigned  to  them  originally 
by  Bright  for  clinical  reasons.  Malignancy,  apart  from  any  as- 
sociation with  cancerous  structure,  is  always  indicated  histologi- 
cally by  a  tendency  to  the  production  of  a  form  of  tissue  which 
is  young  and  immature,  and  this  is  certainly  the  condition  of 
these  ovaless  ovisacs. 

As  a  matter  of  fact,  ovarian  cystomata  are  a  great  deal  of- 
tener  malignant  than  has  yet  been  admitted.  The  recovery  from 
an  ovariotomy  is  generally  so  rapid  and  easy  that  at  the  end  of 
a  month  we  say  "cured,"  and  discharge  the  patient.  But  a  num- 
ber of  these  ''cures"  die  speedily  of  cancer  of  the  peritoneum 
or  of  other  organs,  and  the  more  our  primary  mortality  from 
the  operation  has  diminished,  the  more  numerous  have  become 
these  secondary  deaths  from  cancer,  occurring  between  three 
and  thirty  months  after  the  operation. 

A  few  months  ago  I  removed  an  ovarian  tumor  from  a  child 
aged  twelve,  and  did  not  see,  eitlicr  in  the  tumor  or  in  the  abdo- 
men, a  single  trace  of  malignant  disease.  She  recovered  from 
the  operation,  but  died  within  the  month  with  cancer  in  all  the 
large  organs.     This  singular  sequence  requires  explanation,  and 


OVAllIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      141 

I  believe  that  has  now  been  arrived  at,  the  last  link  being  sup- 
plied by  the  work  of  De  Sinety  and  Melassez  ;  and  if  the  obser- 
vations be  correct,  then  a  bright  light  is  shed  by  them  on  the 
whole  question  of  cancer.  Elsewhere  ("  Diseases  of  Women," 
1877)  I  have  said:  "Histologically,  the  characters  of  cancer  are 
essentially  those  of  immature  and  reckless  cell-proliferation,  the 
presence  of  numerous  nuclei,  both  in  the  cells  and  free,  suggest- 
ing the  idea  that  they  have  had  no  time  to  become  full-growii; 
and  I  have  never  failed  to  find  evidence  that  the  primary  changes 
take  place  in  the  epithelium."  The  bearing  of  this  will  be  seen 
more  fully  later  on,  when  I  speak  of  cancer  of  the  ovary,  but  at 
present  it  leads  up  to  the  remarkable  discovery  of  De  Sinety  and 
Melassez,  to  which  I  have  alluded. 

"If,  then,"  say  these  authors,  "we  cannot  absolutely  deny 
the  possibility  of  the  formation  of  a  large  cyst  of  the  ovary  at 
the  expense  of  a  follicle,  it  may  be  seen  that  this  formation  does 
not  appear  to  result  from  a  simple  dilatation  of  these  follicles,  as 
many  have  said,  and  that  we  must  admit  a  destruction  of  the 
ovules  and  a  transformation  of  the  epithelium  when  the  follicles 
exceed  a  certain  volume."  It  will  afterwards  be  seen  that  there 
is  probably  an  error  in  the  last  clause  of  this  quotation,  in  that  the 
cause  is  put  for  the  effect;  but  it  is  in  the  establishment  of  the  fact 
of  the  change  in  the  epithelium,  or  rather  in  the  interpretation  of 
it,  that  the  merit  lies.  I  had  long  been  quite  familiar  with  the  fact 
that  between  the  epithelium  of  a  healthy  Graafian  follicle  and 
that  of  a  large  ovarian  cyst  there  was  a  great  difference.  I  had 
also  ascertained  the  fact  that,  in  an  ovarian  cystoma  where 
ovules  were  to  be  found  (Rokitansky's  tumor,  or  the  multiple 
cystoma),  the  epithelium  remains  as  it  is  in  the  Graafian  follicle. 
I  had  concluded,  therefore,  that  the  cyst  in  the  latter  case  was 
merely  the  result  of  follicular  dropsy,  and  that  therefore  proba- 
bly all  ovarian  cysts  were  the  same;  but  I  had  not  seen,  in  the 
alteration  of  the  epithelium,  the  explanation  of  the  marvellous 
difference  in  the  two  kinds  of  tumors,  nor  that  here  we  might 
find  an  explanation  of  the  growth  of  ovarian  cystomata.  Such, 
however,  I  now  believe  to  be  the  case. 

Among  other  facts  which  lead  me  to  the  conclusions  which  I 
propose  now  to  discuss  were  the  absolute  resemblance  between 
the  arrangements  of  the  blood-vessels  of  a  Graafian  follicle  and 
those  of  an  ovarian  cystoma  which  has  not  been  altered  by  rup- 
ture, tapping,  inflammation,  or  malignant  degeneration.  If  such 
a  cyst  be  carefully  injected,  cut  into  sections,  and  compared,  in 
the  matter  of  its  vascular  arrangements,  with  a  Graafian  folli- 
cle either  before  or  after  its  rupture,  no  difference  can  be  seen. 
The  description  of  these  will  be  seen  in  the  first  chapter.     Roki- 


142  DISEASES   OF   THE   OVARIES. 

tansky,  Cruveilhier,  Schroeder,  Arthur  Farre,  and  De  Sinety  all 
record  observations— to  which  I  might  add  several — of  cysts 
which  had  clearly  been  produced  in  the  follicle  after  its  rupture 
by  a  continuation  and  recurrence  of  the  hemorrhage,  and  which 
have  been  called  haematic  cysts. 

The  theory,  therefore,  of  this  method  of  growths  of  cystomata, 
is  that  there  is  a  reversion  to  the  premoliminal  condition  of  the 
ovary,  so  far  as  the  ova  of  the  affected  ovisacs  are  concerned. 
The  whole  ovary  does  not,  of  course,  become  simultaneously 
implicated,  and  matured  ova  may  still  be  given  off  by  some  ovi- 
sacs still  unaffected  and  within  reach  of  the  Fallopian  fimbriae. 
Impregnation  may  thus  occur  from  a  degenerated  ovary,  though 
it  is  much  more  likely  to  occur  from  the  one  which  remains 
healthy. 

We  have  in  these  facts  the  reason  that  these  adenoid  tumors 
occur  with  greatest  frequency  during  menstrual  life,  if  indeed  a 
future  experience  may  not  yet  show  that  they  do  so  exclusively. 
The  menstrual  congestion  and  excitement  induces  a  dropsical 
distention  and  growth  of  a  cell  which  would  not  be  so  perverted 
during  childhood  or  senility,  when  its  blood-supply  would  be 
sufficient  only  for  passive  nutrition. 

The  growth  of  cysts  in  the  walls  of  the  major  sacs,  appearing 
sometimes  outside  and  sometimes  within  in  great  numbers,  de- 
pends wholly  on  the  relation  of  the  original  adenoid  tissue  to 
the  cyst- wall ;  and,  as  that  wall  grew  primarily  in  that  tissue 
and  surrounded  by  it,  it  would  be  indeed  surprising  if  it  did  not 
carry  along  with  it  in  its  expansion  some  of  the  cells  of  the 
couclie  ovigene  from  which  it  sprang.  These  displaced  cells  have 
in  their  turn  a  stimulus  for  development,  prematurely  pei-haps, 
on  account  of  the  increased  haemic  activity  of  their  abnormal 
surroundings,  due  to  the  growth  of  the  sac.  They  also  go  through 
the  process  of  dropsical  distention,  developing  no  ova,  not  rup- 
turing, but  becoming  secondary  cysts — perhaps  ultimately  to 
rival,  or  even  to  excel  that  which  has  preceded  them,  on  which 
they  grew,  and  of  which  they  have  been  supposed  to  be  the  off- 
spring. 

Sometimes  these  intracystic  growths  line  the  cavity  of  the 
major  cyst  like  an  eruption  of  small-pox.  In  the  case  of  a  tumor 
which  was  removed  by  my  colleague,  Mr.  C.  J.  Bracey,  hundreds 
of  little  separate  cysts  lined  the  major  sac  of  the  tumor,  as  if  the 
whole  adenoid  tissue  had  been  spread  on  the  inner  surface  as  the 
cyst  grew,  and  as  if  it  were  degenerating;  and  I  have  no  doubt 
tliat  this  was  really  tlie  case,  for  these  little  cysts  were  all  Graaf- 
ian follicles  beyond  a  doubt. 

The  great  change  effected  within  the  Graafian  follicles,  which 


OVAEIAlSr  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      143 

is  doubtless  that  to  which  they  owe  their  subsequent  development 
as  cysts,  lies  in  the  epithelium.  To  quote  the  words  of  the  French 
writers:  "The  epithelium  in  these  new  formations  shows  every 
possible  variety;  but  in  none,  not  even  those  which  simulate  the 
Graafian  follicles,  have  we  found  any  epithelium  similar  to  that 
of  the  follicles,  neither  have  we  ever  found  any  ovules  in  their 
interior."  But  they  very  carefully  point  out  that  this  change  is 
by  no  means  effected  suddenly,  nor  is  it  extended  uniformly  over 
the  whole  surface  of  the  cyst. 

Speaking  of  the  pathogenia  of  follicular  dropsy,  they  say: 

*'  In  all  the  cases  we  have  just  stated  the  follicular  epithelium 
was  normal  in  its  form  as  in  its  dispositions,  although  it  must 
have  been  the  seat  of  a  certain  degree  of  proliferation,  since  it 
covered  a  larger  surface,  the  volume  of  the  follicle  being  aug- 
mented. The  ovule  could  be  detected  in  a  tolerably  large  num- 
ber of  follicles,  even  in  the  largest,  and  it  did  not  appear  altered. 
The  lesion  appears  then  to  consist  in  an  augmentation  of  the 
follicles,  and  in  a  greater  quantity  of  follicular  liquid.  We  can- 
not say  whether  this  liquid  is  or  is  not  modified  in  composition, 
if  the  secretion  is  or  is  not  altered." 

In  those  cavities  which  they  regard  as  pseudo-follicles,  that 
is,  resembling  in  every  particular  save  that  of  their  epithelial 
lining  the  follicles  they  have  just  left,  De  Sinety  and  Melassez 
note  that  "the  differences  are  still  more  considerable.  The  epi- 
thelium which  lines  these  cavities  resembles  in  nothing  that  of 
the  follicles.  There  are  found  in  it  cylindrical  epithelial  cells 
more  or  less  voluminous,  cells  with  cilia  vihratilia,  sometimes 
even  caliciform  cells.  The  different  kinds  of  epithelium  may  be 
observed  in  the  same  cavity.  In  general  these  cells  are  disposed 
in  a  single  row. 

"In  no  cavity  did  we  find  anything  that  in  any  way  resem- 
bled an  ovule  or  a  proligerous  disc.  The  contents  are  a  transpar- 
ent liquid,  more  or  less  fluid,  coagulating  and  becoming  opaque 
at  the  contact  of  alcohol,  reassuming  its  fluidity  and  transpar- 
ency in  water,  and  showing  in  its  interior  granulations  and 
degenerated  cells,  proceeding  no  doubt  from  the  epithelial  in- 
vestment of  the  walls.  In  one  of  these  cavities  there  existed 
large,  radiated  cells  disseminated  in  the  contents,  which  gave  it 
the  aspect  of  mucous  tissue." 

The  only  points  concerning  the  epithelium  in  which  my  own 
observations  do  not  entirely  concur  with  those  of  the  writers  I 
am  quoting  are,  first,  the  frequency  with  which  they  appear  to 
have  met  with  cells  furnished  with  vibratile  cilia.  I  have  found 
these  in  only  one  of  the  tumors  I  examined,  and  that  was  a 
dermoid  cyst,  having  abundant  indications  of  immature  nerve- 


144  DISEASES   OF   THE    OVARIES. 

structure;  these  cells  I  regarded  as  probably  representing  the 
lining  membrane  of  a  cerebral  ventricle.  Beneke  speaks  of  hav- 
ing found  them  once  or  twice,  but  I  do  not  know  that  any  other 
observers  have  seen  them  frequently.  De  Sinety  and  Melassez 
speak  even  of  having  seen  them  in  a  very  fresh  specimen  with 
the  cilia  in  motion.  From  the  general  accuracy  of  the  observa- 
tions of  these  gentlemen  I  am  bound  to  accept  these  remarkable 
statements,  but  I  do  not  see  that  the  occurrence  of  these  cells 
can  be  looked  upon  as  having  any  importance  or  significance. 
The  second  point  of  difference  between  us  is  that  in  the  dropsi- 
cal follicles  containing  ova  I  have  found  the  epithelium  quite 
normal  in  arrangement  and  appearance. 

We  have,  however,  from  them  a  complete  establishment  of 
the  facts  that  I  have  so  often  seen,  that  we  may  have  in  the 
same  ovary — indeed,  we  may  have  in  the  same  cyst — indications 
of  a  reversion  of  type  in  epithelial  growth;  that  is,  we  may  have 
the  normally  cylindrical  cells  at  one  part  of  the  lining  membrane 
of  a  large  ovarian  cyst,  while  at  another  part  we  may  have 
round,  immature,  rapidly  growing  cells,  presenting  all  the  ap- 
pearances they  would  possess  upon  a  mucous  surface.  Such 
cells  as  these,  however,  are  not  seen  in  a  Rokitansky's  tumor. 
In  columnar  cells  the  arrangement  is,  of  course,  in  a  layer  single, 
or  nearly  single,  and  the  first  change  from  the  type  is  seen  w^ien 
we  have  cells  increasing  largely  in  size,  becoming  somewhat  ir- 
regular in  shape,  and  having  underneath  another  layer  polyhe- 
dral and  polymorphous.  We  may,  I  think,  accept  the  following 
description  as  perfectly  accurate: 

"  Sometimes  these  are  flat  cells,  with  sinuous  borders,  and 
occasionally  of  considerable  dimensions.  Seen  in  front,  in  silver 
preparations,  they  simulate  a  pavement  with  irregular  designs, 
quite  different  from  the  very  regular  mosaic  formed  by  the  cylin- 
drical epithelium.  Seen  in  profile,  on  sections,  their  thickness 
is  found  to  be  somewhat  variable;  it  is  generally  larger  on  a 
level  with  the  nucleus.  It  possesses  one  and  sometimes  several 
nuclei. 

"  Sometimes,  instead  of  flat  cells,  we  have  thick,  voluminous 
ones,  of  the  most  varied  and  fantastic  forms.  Some  are  seen 
presenting  a  broad  base  of  implantation,  and  terminating  in  a 
narrow,  tapering  extremity,  which  causes  them  to  resemble 
cones.  Others,  on  the  contrary,  are  only  attached  to  the  wall 
by  a  thin  pedicle,  more  or  less  long,  while  their  extremity  is  dis- 
tended, which  gives  them  the  appearance  of  clubs.  There  are 
some  that  are  broad  at  the  base,  broad  at  their  free  extremity, 
and  of  which  the  two  voluminous  extremities  are  united  by  a 
more  or  less  narrow  neck.    We  have  seen  some  which  presented 


OVAKIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      145 


successively  two  constricted  portions,  and  consequently  three 
distended  portions;  others  which  were  carried,  like  grapes,  upon 
a  ramified  pedicle.  The  free  extremities  have  a  tendency  to 
approach  the  spherical  form,  while  the  others  are  polyhedric 
through  reciprocal  pressure. 

"  The  protoplasma  of  these  singular  cells  is  in  general  granu- 
lous,  with  large  grains.     It  takes  a  brownish  yellow  color  under 
the  action  of  picrocarminate,  except  in  the  portions  constricted  or 
in  the  form  of  pedicles,  which  portions 
are   more   homogeneous   and   more   re- 
fractive.   These  generally  possess  large 
nuclei,  with  one  or  several  voluminous 
nucleoles.      Those  that  present  several 
distended  portions  have  nuclei  in  each 
of  these  portions.     It  will  be  perceived 
that  they  are  elements  that  proliferate 
and  bud  with  very  great  activity." 

The  epithelium  of  a  cyst-cavity,  after 
having  undergone  the  changes  of  type 
already  described,  takes  on  a  further 
growth,  and,  departing  from  an  arrange- 
ment in  a  single  layer,  as  seen  in  the 
normal  follicle  (Fig.  12),  or  in  the  cyst 
still  containing  an  ovum,  it  increases  in 
thickness,  adding  layer  upon  layer  of 
the  immature  cells.  As  these  layers 
grow,  the  cells  alter  more  and  more 
from  the  normal  and  adult  forms,  and 
finally  cease  to  have  any  resemblance  to 
them.  Waldeyer,  as  well  as  De  Sinety 
and  Melassez,  have  fully  confirmed  my  observations  on  this  point. 
The  new  layers  are  not  uniformly  distributed  over  the  interior 
of  the  same  cyst,  and  they  are  often  so  localized  as  to  form 
elevated  patches,  or  even  tubercles,  on  the  inside  of  the  cyst. 
To  the  naked  eye  these  often  look  very  like  cancer,  and  on  mi- 
croscopic examination  they  have  all  the  appearances  which  I 
have  already  described  as  belonging  to  that  tendency.  The 
French  authorities  I  have  so  often  quoted  say  of  these  masses  : 
"They  have  the  aspect  of  carcinomatous  fungosities,  and  they 
appear  also  to  have  their  malignity."  Boettcher  and  Waldeyer, 
besides  other  authorities,  fully  support  my  conclusions. 

In  some  tumors  we  find  velvety-looking  tufts  hanging  from 

the  walls  into  the  interior;  and  these  are  found,  on  examination, 

to  consist  of  a  basis  of  nucleated  fibrous  tissue — in  fact,  ovarian 

stroma — lined  on  each  side  of  their  many  branches  by  regular 

10 


Altered  Epithelium  from 
Walls  of  Ovarian  Cysts.  (After  De- 
Sinety  and  Melassez.) 


146  DISEASES   OF   THE   OVAKIES. 

columnar  epithelium,  or  by  epithelium,  of  the  immature  forms. 
They  are  sometimes,  in  fact,  transformed  into  pediculated  masses 
of  villous  cancer. 

As  these  structures  divide  and  redivide  into  branches,  they 
very  much  resemble  trees,  and  therefore  have  had  conferred 
upon  them,  among  other  names,  that  of  intracystic  dendritic 
growth.  If  a  cyst  in  which  they  exist  be  injected  and  the  sec- 
tions stained,  they  will  be  found  to  consist  merely  of  the  remains 
of  follicles  which  have  burst  in  their  efforts  to  become  cystic, 
the  skeleton  branches  retaining  the  epithelium  of  the  cysts  which 
formerly  were  on  each  side  of  it.  By  the  growth  of  subsequent 
cysts  these  papillary  remains  are  often  forced  into  irregular  and 
very  complex  folds,  the  apparent  complexity  of  which  may  be 
greatly  increased  by  the  accidents  of  the  section. 

We  have  here,  therefore,  among  otlier  things,  an  explanation 
of  the  extraordinary  differences  of  opinion  which  have  been  ex- 
pressed regarding  the  results  of  microscopic  examination  of  the 
contents  of  ovarian  tumors.  Many  years  ago  Professor  John 
Hughes  Bennet  described  what  he  termed  an  ''ovarian  cell." 
Dr.  Drysdale,  Mr.  Thornton,  and  several  others,  have  all  fallen 
into  a  similar  error  in  believing  that  any  one  form  of  cell  could 
be  made  diagnostic  of  these  curious  growths. 

In  the  second  edition  (18G8)  of  his  book  on  "  Ovarian  Dropsy" 
Mr.  Baker  Brown  discusses  the  views  of  Professor  Bennet.  of 
Edinburgh,  who  believed  that  it  was  possible,  by  microscopic  in- 
vestigation, to  decide  as  to  whether  the  fluid  was  ovarian  or 
peritoneal.  Mr.  Brown,  in  conjunction  with  Mr.  Nunn,  seems  to 
have  gone  very  fully  into  this  matter,  and,  in  the  words  of  the 
latter,  it  seems  to  have  been  decided  as  follows: 

"  I  am  inclined  to  say,  as  the  result  of  many  examinations 
of  different  specimens  of  ovarian  fluid,  that  the  most  constant 
characteristic  of  such  fluid  is  its  containing,  in  greater  or  less 
abundance,  cells  gorged  with  granules,  and,  in  addition,  circum- 
ambient granules  having  the  same  measurements  as  those  en- 
compassed by  the  cell-wall.  At  one  time  I  considered  the  size 
of  these  granules  was  constant,  but  subsequent  observations  have 
convinced  me  of  the  incorrectness  of  this  conclusion.  The  size 
of  the  gorged  cells  and  of  the  granules  varies  greatly,  even  in  the 
fluids  from  different  cysts  of  the  same  ovary."  "  In  the  present 
state  of  our  knowledge  I  do  not  think  we  are  justified  in  assert- 
ing that  the  nature  of  the  fluid  would  be  diagnostic  of  the  dis- 
ease which  gives  rise  to  its  production.  What  I  believe  to  be 
the  value  of  a  microscopical  examination  of  the  fluid  is  that  it 
may  serve  to  strengthen  an  opinion,  but  alone  it  ought  not  to 
decide  one." 


.6^8^ 


'  ^S»',«s  «  *'<k5'„« 


•^^^ 


=><^."/<^of^r 


#.  H 


.jri  -diss, 


IS-- 


■si 


-■■.-.';v-^>^**^ 


_>.ifl 


■H    ^ 

o  g 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      147 

We  may  also  find,  from  the  observations  of  De  Sinety  and 
Melassez,  a  confirmation  of  what  I  advanced  many  years  ago  in 
a  discussion  upon  tiiis  subject:  tliat  there  was  no  kind  of  cell  of 
epithelial  origin  that  it  was  not  possible  to  obtain  from  the  cyst- 
cavities  of  an  ovarian  tumor.' 

In  the  last  paragraph  quoted  from  the  French  authors  there 
is  a  most  concise  description  of  what  must  also  be  regarded  as  a 
tendency  to  malignant  growth;  that  is,  the  reversion  of  type  in 
the  production  of  these  cells  toward  immature,  incomplete,  and 
rapidly  growing  elements  which  are  practically  cancerous. 

This  of  course  at  once  explains  the  clinical  fact  which  all  ova- 
riotomists  are  quite  familiar  with,  and  to  which  Dr.  Keith  has 
especially  drawn  attention — that  the  rupture  of  certain  cysts,  on 
the  escape  of  their  fluid  into  the  peritoneal  cavity,  is  followed  by, 
or  at  least  is  associated  with,  the  infection  of  the  general  perito- 
neal surface  with  papillary  cancer,  this  accident  having  a  uni- 
formly fatal  result.  On  the  other  hand,  I  have  seen  over  and 
over  again  the  same  cells  and  the  same  expressions  of  immature 
growth  in  the  peritoneum,  without  the  presence  of  any  ovarian 
tumor;  and  only  on  the  morning  in  which  this  sentence  was 
written  I  opened  the  abdomen  of  a  patient  placed  under  my  care 
by  Mr.  Oliver  Pemberton,  in  which  I  found  exactly  the  condition 
so  accurately  described  by  De  Sinety  and  Melassez  in  the  above- 
quoted  sentence,  but  with  no  ovarian  tumor.  ISTow  that  we  open 
the  abdominal  cavity  with  great  frequency,  we  are  constantly 
coming  across  this  peculiar  form  of  malignant  disease,  and  w^e 
find  it  is  by  no  means  confined  to  the  inside  of  ovarian  tumors 
or  to  the  peritoneal  cavity,  even  when  no  tumor  exists  there,  for 
I  have  had  occasion  to  examine  pieces  of  the  pleura  and  of  the 
pericardium  where  exactly  the  same  appearances  were  found.  ^ 

The  conclusion  from  all  this  is  that  to  which  I  have  already 
pointed,  that  the  growth  of  ovarian  tumors  is  associated  with  a 
tendency  toward  malignant  disease,  which  finds  constant  clini- 
cal expression,  and  which  receives  its  explanation  in  the  mar- 

'  Dr.  Mathews  Duncan  speaks  of  this  question  with  his  usual  force  in  these  words : 
"  In  fact,  we  have,  in  all  departments  of  ovarian  diagnosis,  more  to  admire  in  the  zeal 
and  diligence  of  histologists,  in  regard  to  the  fluids,  than  in  the  exactness  and  relia- 
bility of  the  practical  results  they  can  show." 

'■'  But  my  most  recent  experience  tends  to  show  that  there  are  two  forms  of  pap- 
illoma associated  with  ovarian  tumors,  one  malignant,  and  one  not  so.  The  latter 
speedily  disappears  after  the  removal  of  the  tumor  and  the  patient  gets  quite  well, 
though  its  naked-eye  appearances  are  quite  indistinguishable  from  those  of  the  malig- 
nant kind.  I  have  had  two  cases  within  the  last  year,  aged  57  and  .38  respectively, 
where  I  have  left  large  masses  of  papilloma,  fixing  the  uterus  in  both  cases.  Since 
the  operations  these  masses  have  entirely  disappeared,  and  the  patients  are  both  in 
perfect  healtli. 


148  DISEASES   OF  THE   OVARIES. 

vellous  changes  we  find  produced  in  the  epithelial  linings  of  its 
cysts.  Much  more  requires  to  be  done  in  the  study  of  this  most 
interesting  question,  and  doubtless,  when  the  method  of  its  prog- 
ress is  made  clear,  we  may  find  some  indications  for  a  more  sure 
prevention  of  it.  One  thing  I  am  certain  it  clearly  establishes, 
and  that  is  the  absolute  propriety  of  removing  ovarian  tumors 
at  a  very  much  earlier  stage  of  their  existence  than  has  been, 
till  recently,  the  accepted  rule  in  practice.  If  these  epithelial 
changes  are  progressive — as  doubtless  they  are,  and  if  they  are 
malignant — as  I  certainly  believe  them  generally  to  be,  then, 
acting  upon  the  principles  which  guide  us  in  the  treatment  of  all 
tumors,  we  ought  to  remove  an  ovarian  c.ystoma  early  in  its  his- 
tory, before  these  changes  have  been  effected,  and  certainly  be- 
fore there  is  any  risk  of  cyst-rupture.  Finally,  we  ought  to  regard 
the  operation  of  tapping  as  one  which  ought  to  be  discarded, 
save  under  very  exceptional  circumstances,  because  not  only  is 
it  fraught  with  considerable  immediate  danger,  but  it  seems  to 
possess  a  still  more  important  secondary  risk,  which  has  until 
lately  been  almost  overlooked.  I  may  say  that  in  my  own  prac- 
tice it  is  an  operation  never  performed,  unless  I  am  certain  the 
tumors  cannot  be  removed. 

There  is  one  fact  which  may  be  quoted  in  support  of  the  views 
advanced  by  De  Sinety  and  Melassez,  to  which  they  have  not 
drawn  attention,  but  the  significance  of  which  becomes  apparent; 
that  is,  that  while,  in  the  cysts  of  the  tumors  which  I  shall  after- 
ward describe  as  possessing  ova,  the  contents  are  always  limpid, 
whereas  in  the  cysts  where  the  changes  have  occurred  the  con- 
tents are  mucous,  viscous,  highly  albuminous,  and  often  bloody; 
in  fact,  they  present  all  the  characteristics  which  the  contents 
of  mucous  cysts  would  possess.  It  might  not  be  inappropriate 
also  to  point  out  here  that  the  arguments  I  have  given  above 
also  point  in  the  direction  of  establishing  for  cancer  a  local  ori- 
gin. We  have,  then,  ovarian  tumors  with  well-pronounced  and 
distinctive  characters,  possessing  the  power  of  infecting  the  sys- 
tem generally  with  cancer,  as  they  most  undoubtedly  do  when 
their  removal  is  too  long  delayed,  or  wlien  they  have  ruptured 
or  been  frequently  tapped;  and,  on  the  other  hand,  we  have  tu- 
mors with  the  same  characters,  but  which  have  never  been 
tapped  and  have  not  ruptured,  but  have  been  removed  early  in 
their  history.  By  the  early  removal  of  these  latter  tumors  we 
remove  the  source  of  the  systemic  infection,  and  prove,  it  seems 
to  me,  a  local  origin  for  cancer — as  far  as  the  ovary  is  concerned, 
at  least. 

There  comes  then  the  question — if  we  should  see  any  of  these 
altered  and  sprouting  cells  in  fluid  removed  from  a  cyst  or  from 


OVARIAN  TUMORS,  CONDITIONS  WlllCn  SIMULATE  THEM.      140 

a  serous  cavity — Should  we  set  the  case  down  as  being  hopelessly 
malignant,  and,  in  the  case  of  an  ovarian  cyst,  refuse  on  that 
account  to  operate?  I  certainly  could  not  answer  these  questions 
in  the  affirmative.  I  believe  that  such  ajjpearances  indicate  the 
high  road  to  cancer,  but  it  is  possible  that  the  goal  may  never  be 
reached,  I  think  it  perfectly  certain  that  removal  of  the  tumor 
may  arrest  the  progress  of  the  change  before  a  general  iufection 
is  reached.  Dr.  Mathews  Duncan  very  well  points  out  that  the 
ovary  is  in  every  way  the  most  isolated  organ  in  the  body.  Re- 
moval of  a  cystoma  in  which  such  changes  are  being  effected,  at 
an  early  stage,  may  avert  a  systemic  affection;  and,  as  a  matter 
of  fact,  I  have  observed  all  these  changes  in  tumors  which  I  re- 
moved many  years  ago,  and  the  patients  from  whom  they  were 
cut  out  are  alive  and  well  at  this  date.  In  one  case  the  period 
which  has  elapsed  is  eleven  years. 

Upon  the  question  of  the  origin  and  diagnosis  of  this  condi- 
tion a  good  deal  has  been  written,  especially  by  Dr.  Foulis,  of 
Edinburgh,  and  Mr.  Thornton,  of  London.  They  both  claim  the 
credit  of  having  discovered  masses  of  sprouting  epithelium,  both 
in  the  cystic  fluid  and  in  that  of  the  peritoneum,  which  will 
enable  us  to  diagnose  cases  of  cancer.  After  a  very  large  experi- 
ence, both  of  microscopic  manipulation  and  of  cases  of  this  char- 
acter, I  must  absolutely  dissent  from  the  views  they  express. 
Dr.  Foulis  goes  so  far  as  to  say  that  the  absence  of  these  sprout- 
ing masses  from  ascitic  fluid  is  an  almost  certain  sign  of  the 
absence  of  malignant  peritonitis  and  malignant  ovarian  tumor. 
But  I  have  had,  in  at  least  two  cases,  reason  to  suspect  malignant 
tumors,  when  I  found  none  of  these  cells  in  the  fluid,  and  yet  I 
found  abundant  reason  afterward  to  know  that  my  suspicions 
were  correct.  In  fact,  I  place  no  reliance  on  the  presence  or  ab- 
sence of  these  cells  in  fluid  removed  by  tapping,  and  as  I  never 
tap  removable  tumors  at  all  now,  I  never  have  any  occasion  to 
look  for  them,  or  any  opportunity.  The  changes  to  which  their 
presence  is  due  certainly  lead  to  a  malignant  condition  in  their 
later  stages,  but  their  presence  is  no  guide  for  a  prediction  that 
the  patient  will  die  of  cancer,  and  it  is  the  best  of  all  arguments 
for  the  speedy  removal  of  the  tumor. 

It  is  also  quite  certain  that  this  form  of  papillary  cancer  fre- 
quently arises  long  after  the  removal  of  an  ovarian  tumor  under 
circumstances  which  make  it  extremely  unlikely  that  the  tumor 
should  be  regarded  as  its  cause.  They  are  both  probably  the 
result  of  the  same  condition,  whatever  that  may  be.  Thus,  in 
the  Lancet  of  October  25,  1875,  I  published  a  brief  note  of  a  cas« 
of  ovariotomy  in  a  young  girl,  in  which  the  operation  was  mad* 
to  cure  a  complete  protrusion  of  the  uterus.     The  operation  wa  •. 


150  DISEASES    OF   THE    OVARIES. 

performed  on  August  18, 1875,  and  after  her  recovery  from  it,  until 
about  May,  1877,  she  remained  in  perfect  health.  She  came  to  me 
then  vp^ith  indications  of  a  general  failure  in  her  health,  obscure 
pelvic  pains,  a  slight  amount  of  ascites,  and  a  small  fixed  mass 
behind  the  uterus.  For  a  month  she  took  chalybeates,  and  re- 
turned to  me  much  improved  in  her  general  health,  but  with 
more  ascites  and  with  the  retro-uterine  mass  increased.  In  the 
beginning  of  July  the  increase  of  the  ascitic  effusion  was  so 
marked  that  it  became  evident  something  must  be  done.  The  age 
of  the  patient  (nineteen)  made  me  hesitate  to  pronounce  it  a  case 
of  cancer  of  the  peritoneum,  to  which  view  I  strongly  inclined. 
The  only  alternative  which  seemed  to  me  reasonable  was  that 
the  other  ovary  had  become  cystic,  was  fastened  in  the  pelvis, 
and  was  producing  the  ascites  by  pressure  on  veins.  I  deemed 
it  therefore  right  to  make  an  exploratory  incision,  and  this  I  did 
on  July  15th.  In  the  operation  the  only  noteworthy  point  was 
the  absolute  perfection  with  which  union  had  taken  place  between 
the  tendinous  structures  divided  in  the  previous  operation — a 
result  which  is  not  always  obtained  after  abdominal  section. 

When  the  peritoneum  was  opened  and  the  fluid  evacuated,  the 
lesion  was  found  to  be  the  papillary  form  of  cancer  of  the  perito- 
neum. Small  papillary  nodules  were  scattered  over  the  whole 
surface  of  the  parietal  peritoneum  within  reach,  and  on  the  sur- 
face of  the  small  intestines.  The  pelvis  was  occupied  by  several 
masses,  the  largest  of  which,  about  the  size  of  an  orange,  seemed 
to  embrace  the  rectum,  and  this  it  was  which  had  been  previously 
felt  from  the  vagina.  At  the  posterior  surface  of  the  uterus 
several  nodules  were  felt,  but  the  remaining  ovary  (the  left  one) 
was  perfectly  healthy.  The  right  cornu  of  the  uterus  was  tied 
up  to  the  lower  angle  of  the  wound  by  a  firm  band  about  a  third 
of  an  inch  in  diameter,  representing  the  pedicle  of  the  tumor  re- 
moved nearly  two  years  before.  She  recovered  from  this  opera- 
tion, went  home,  and  died  after  great  suffering,  on  the  27th  of 
August.  I  have  again  examined  the  tumor  removed  from  her 
with  great  care,  and  can  discover  no  appearance  of  papillary 
growths  about  it,  and,  as  she  remained  in  perfect  health  for  at 
least  eighteen  months  after  the  operation,  I  can  only  regard  the 
access  of  the  papillary  growth  as  an  independent  event. 

There  is  anotlier  condition  associated  with  malignancy  in  ova- 
rian tumors — hemorrhage  into  their  cavity.  I  have  seen  one 
case  where  this  occurred,  yet  where  the  tumor  was  not  cancer- 
ous; yet,  as  a  rule,  its  occurrence  must  always  be  regarded  as 
suspicious. 

The  following  is  a  typical  example  of  a  case  of  cystic  tumor 
of  the  ovary  which  has  undergone  malignant  degeneration — one 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      151 

in  which  the  mistakes  I  fell  into  have  been  of  immense  service 
to  me  since. 

On  March  2,  1876,  I  was  summoned  to  the  neighborhood  of 
Llangollen  to  see  a  patient  under  the  care  of  Dr.  Price  Jones,  from 
whom  I  received  the  following  history:  She  had  been  confined 
of  her  first  child  on  February  21st.  The  labor  was  natural,  the 
child  still-born,  the  placenta  somewhat  friable,  but  expelled  with- 
out difficulty.  She  did  not,  however,  diminish  in  size  as  much 
as  usual  after  labor,  and  in  a  day  or  two  symptoms  of  peritonitis 
appeared.  On  February  28th  her  pulse  and  temperature  fell  to 
100  and  99°  respectively,  and  the  only  matter  of  note  was  that 
the  abdomen  was  greatly  distended  by  fiuid.  At  2  a.m.,  on  March 
2d,  I  found  the  abdomen  so  distended  as  to  have  quite  a  drum- 
like tightness,  the  temperature  quite  normal,  but  the  pulse  about 
180  and  the  respirations  50  in  the  minute.  These  symptoms  were 
regarded  as  due  solely  to  the  mechanical  interference  with 
breathing.  The  uterus  was  fixed  high  up  in  a  solid,  doughy  mass, 
which  could  only  be  blod-clot.  No  intestinal  resonance  could  an}'- 
where  be  discovered.  Generally  over  the  abdominal  surface  a 
wave  of  fluctuation  could  be  felt,  but  here  and  there  it  was  less 
distinct.  Palpation  gave  no  assistance  on  account  of  the  tenseness 
of  the  integument.  The  conclusion  I  came  to  was  that  it  must 
be  a  case  of  intraperitoneal  hsematocele  followed  by  some  serous 
effusion;  for  I  regarded  it  as  impossible  that  it  could  be  all  blood. 
I  tapped  the  abdomen,  and  removed  about  three  quarts  of  fluid, 
which  seemed  like  pure  venous  blood.  This  gave  immediate 
relief;  and  when  I  left  her,  at  7  a.m.  on  March  3d,  the  pulse  had 
fallen  to  120  and  the  respirations  to  32  in  the  minute.  The  relief 
of  the  tension  also  enabled  me  to  discover  floating  doughy 
masses,  which  I  regarded  as  blood-clot.  She  improved  consider- 
ably after  this,  and  was  brought  to  Birmingham  on  March  30th. 
The  journey  was  delayed  as  long  as  possible;  but  she  became  so 
urgent  for  something  more  to  be  done  that  it  was  impossible  to 
appease  her  any  longer.  The  exertion  of  removal  was,  however, 
evidently  too  much  for  her,  as  on  the  following  day  a  passive 
oedema  of  the  left  thigh  occurred,  and  this  was  followed  by  an 
increase  in  the  size  of  the  abdomen.  This  latter  condition  be- 
came so  serious  on  April  2d  that  it  was  necessary  to  tap  her 
again,  and  eight  pints  and  a  half  of  a  fluid  which  seemed  like 
equal  parts  of  blood  and  water  were  removed.  The  breathing 
was  greatly  relieved  by  this  for  a  few  hours ;  but  on  the  after- 
noon of  the  next  day  it  became  again  very  bad,  and,  as  it  then 
seemed  to  come  from  the  chest,  Dr.  Heslop  was  called  to  see  her 
in  my  absence.  It  was  then  discovered  that  the  left  pleura  was 
full  of  fluid,  and  three  pints  and  a  half  were  immediately  re- 


152  DISEASES   OF  THE   OVARIES. 

moved  from  it  by  aspiration.  This  quite  relieved  her  breathing. 
As  the  fluid  was  distinctly  tinged  with  blood,  Dr.  Heslop  sug- 
gested that  there  might  be  some  malignant  disease  in  the  chest; 
but,  on  careful  discussion  of  the  whole  aspects  of  the  case,  there 
was  no  sufficient  data  to  arrive  decisively  at  such  an  unfavorable 
conclusion,  as  it  was  thought  possible  that  the  pleural  effusion 
might  have  been  the  result  of  mechanical  pressure  from  the  ab- 
domen. On  April  4th,  oth.  and  Gth  she  was  very  comfortable ; 
and,  after  careful  discussion,  it  was  determined  to  open  the 
abdomen  to  determine  if  anything  could  be  done  to  arrest  the 
hemorrhage.  In  cutting  open  the  abdomen,  a  line  of  abnormal 
tissue  was  cut  through  which  looked  like  malignant  growth,  and 
then  a  cavity  was  opened  whicli  contained  a  quantity  of  bloody 
fluid  and  thick  layers  of  laminated  fibrin.  As  no  point  of 
hemorrhage  could  be  detected,  and  as  it  was  felt  that  any  dis- 
turbance of  the  structure  might  lead  to  hemorrhage  which  might 
not  be  controllable,  the  cavity  was  washed  out  with  thymol 
solution,  a  drainage-tube  inserted,  and  the  wound  closed.  The 
nature  of  the  case  was  not  made  absolutely  clear  by  the  section, 
as  no  accurate  idea  could  be  formed  as  to  the  nature  of  the  pos- 
terior wall  of  the  hsematocele  cavity.  She  died  on  the  afternoon 
of  April  9th.  The  post-mortem  examination  was  made  by  Dr. 
Saundby,  who  found  that  the  left  pleural  cavity  contained  about 
two  quarts  of  blood-stained  serum,  the  lung  being  quite  collapsed, 
but  healthy.  There  was  a  fungating  ulcerated  growth  about 
the  size  of  a  walnut,  covered  with  blood-clot,  on  the  pleural  sur- 
face of  the  diaphragm.  The  right  pleural  cavity  contained  about 
a  pint  and  a  half  of  similar  fluid,  with  a  similar  growth  on  the 
diaphragm.  Some  of  tlie  mediastinal  glands  were  as  large  as 
hens'  eggs  from  cancerous  infiltration.  The  abdomen  was  occu- 
pied by  a  large  tumor  matted  down  to  the  uterus,  broad  liga- 
ments, and  section,  and  only  after  careful  dissection  could  it  be 
made  out  that  this  mass  was  a  cancerous  tumor  of  the  left  ovary, 
that  into  its  cavity  the  hemorrhage  had  occurred  and  tlie  in- 
cision had  been  made.  It  was  adherent  over  the  whole  of  its 
anterior  aspect  to  the  abdominal  wall.  The  microscopical  ap- 
pearances were  those  of  ence})haloid  cancer. 

Looking  back  on  this  case,  I  of  course  regret  that  I  performed 
abdominal  section;  indeed,  I  did  so  against  my  own  convictions 
and  entirely  at  the  patient's  most  urgent  request.  I  had  the 
advantage  of  the  help  of  Dr.  Marion  Sims  in  the  case,  and  there- 
fore liad  as  good  security  for  avoidance  of  error  as  could  be — yet 
we  were  all  mistaken. 

The  term  colloid,  as  applied  to  tumors  of  the  ovary,  must  be 
held  to  refer  only  to  the  consistency  of  the  fluid  contained  in  them, 


OVAKIAX  TUMOMS,   CONDITIONS  WHICH  SIMULATE  THEM.      153 


and  in  no  way  as  a  point  for  classification.  I  have  never  met 
with  a  description  which  has  persuaded  me  that  the  so-called 
colloid  cayicer,  as  seen  in  the  breast,  intestines,  and  peritoneum, 
has  ever  been  met  with  in  the  ovary.  What  we  see  of  it  is  the 
myxoma  already  described,  and  which  is  always  quite  localized 
in  the  tumor,  a  mere  incident,  as  it  were,  never  forming  the  mass 
of  the  growth.  In  other  organs  it  is  practically  a  malignant  dis- 
ease, but  whether  it  is  so  in  the  ovary  I  do  not  know.  It  is,  as  I 
have  said,  the  reversion  of  the  stroma  of  the  ovary  to  its  young 
form,  and  may  therefore  be  suspected.  The  first  time  I  saw  it  was 
in  a  tumor  sent  to  me  for  examination  by  Mr.  Spencer  Wells,  who 
asked  the  question,  "  Do  you 
think  this  cancer  ? "  In  my 
reply  I  said  I  feared  it  was  ; 
the  stroma  was  so  young  and 
immature  as  to  resemble  per- 
fectly a  myxomatous  growth, 
or  the  canalicular  structure  of 
the  umbilical  cord.  Indeed,  if  I 
had  placed  sections  from  these 
three  structures  under  adjoin- 
ing microscopes,  I  do  not  think 
that  I  have  yet  met  with  the 
histologist  who  could  distin- 
guish between  them. 

An  example  of  this  disease 
was  exhibited  before  the  Ob- 
stetrical Society  of  London,  in 
June,  1878,  and  as  it  illustrates 
not  only  this  disease,  but  the 
fact  that  diseased  ovaries  lead  to  intractable  monorrhagia  which 
kills  the  patient,  I  shall  quote  the  report  in  full.  If  instead  of 
using  a  sponge  tent,  which  merely  had  the  effect  of  killing  the 
enfeebled  patient  by  septic  peritonitis,  the  surgeons  had  removed 
the  patient's  ovaries,  they  would  have  removed  the  cause  of  the 
hemorrhage,  and  probably  have  saved  and  cured  their  patient. 
The  victim,  a  woman  aged  twenty-one,  had  suffered  from  al- 
most constant  hemorrhage  since  her  marriage  three  years  pre- 
viously ;  and  when  admitted  into  Guy's  Hospital  she  was  so 
exhausted  that  transfusion  was  thought  of.  The  hemorrhage, 
however,  was  checked  by  the  use  of  a  sponge  tent  and  the  sub- 
sequent injection  of  warm  water,  but  the  woman  died  ten  days 
later  of  suppurative  peritonitis.  Both  ovaries  were  found  en- 
larged, but  retaining  their  normal  shape  ;  and  it  was  at  first 
thought  that  the  enlargement  was  due  to  acute  inflammation. 


Myxomatous  G^rowth.  of  Ovary. 


154  DISEASES    OF   THE    OVAllIES. 

Microscopical  examination,  however,  showed  that  the  histologi- 
cal characters  of  the  growth  were  those  of  myxoma,  though 
the  harder  portions  exhibited  the  characters  of  sarcoma.  The 
spleen  was  leuksemic.  The  uterine  mucous  ijiembrane  was  dis- 
integrated on  its  surface  (as  shown  in  one  of  the  microscopical 
sections)  and  altered  in  structure,  its  round  cells  appearing 
separated,  as  if  by  fluid  effused  between  them,  and  being  sur- 
rounded by  a  fibrillar  growth,  reminding  one  of  the  state  of 
things  found  in  the  ovaries.  He  would  leave  it,  the  reporter  said, 
to  the  pathologists  to  decide  whether  there  was  any  connection 
between  the  leukaemia,  from  which  the  patient  suffered,  and  the 
myxomatous  enlargement  of  the  ovaries. 

The  structure  of  the  walls  of  ovarian  cystomata  is  tolerably 
uniform,  but  it  is  so  often  altered  by  protracted  growth  and  in- 
flammation of  the  tumor  that  it  may  be  difficult,  in  many  prep- 
arations, to  identify  the  structures.  If  a  tumor  be  examined 
which  has  not  been  so  altered,  it  will  be  found  that  the  structures 
met  with  are  pretty  much  as  follows: 

In  the  first  place,  if  the  outer  surface  of  the  tumor  be  exam- 
ined while  it  is  i)erfectly  fresh,  before  it  has  been  damaged  by 
rough  handling,  and  if  the  preparation  be  made  in  the  way  I 
shall  describe,  it  will  be  found  that  this  membrane  has  all  the 
characters  of  a  normal  serous  surface.  A  mosaic  of  flat,  poly- 
hedrons cells,  with  the  characteristic  cement  substance  between 
them,  will  be  found  extending  uniformly  over  the  surface  of  the 
tumor.  The  method  of  examination  which  I  pursue  is  that  of 
spreading  a  small  portion  of  the  tumor  over  a  slightly  convex 
surface,  such  as  a  watch-glass,  and  placing  it  in  my  freezing 
microtome  with  distilled  water  only.  I  then  screw  it  carefully 
up  to  the  level  of  the  cutting-slab,  and  take  a  thin  slice  off  the 
outside  surface  of  the  tumor.  This  is  immersed  in  a  solution  of 
.5  per  cent,  of  lactate  of  silver,  and  is  then  mounted  in  glycerine 
jelly.  This  treatment  brings  out  all  the  structures  I  have  de- 
scribed in  similar  situations,  and  we  see  the  stigmata  and  sto- 
mata,  with  the  characteristic  endothelium  of  the  latter,  just  as 
we  find  them  in  all  other  serous  pavement  surfaces.  From  the 
endothelium  of  the  stomata  I  have  an  absolute  assurance  that 
the  malignant  growths  of  which  I  have  spoken,  and  of  which  I 
shall  have  to  speak  again,  are  derived.  Tliey  constitute  a  va- 
riety of  epithelioma,  and  are,  in  my  estimation,  analogous  to  the 
nesting  of  the  epithelial  cells  which  we  see  in  skin  cancer.  These 
cells  are  produced  by  a  rapid  and  immature  proliferation  of  the 
endothelium  of  the  stomata.  In  a  favorable  section  they  may 
be  seen  to  be  crowding  out  of  a  stoma,  tearing  asunder  the  rela- 
tions of  the  epithelium  to  its  subjacent  structure;  and  thus  it  is 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      155 

that  they  possess  to  the  naked  eye  and  to  the  toucli  the  peculiar 
characteristics  wliich  have  obtained  for  this  disease  its  special 
names  of  papilloma  and  miliary  cancer.  It  will  be  seen,  there- 
fore, from  this  description,  that  it  differs  in  no  way  from  any 
other  form  of  epithelioma,  and  it  is  to  be  seen  on  the  surface  of 
an  ovarian  tumor  as  often  as  it  is  to  be  seen  either  on  its  inside 
or  upon  the  peritoneum  without  the  presence  of  an  ovarian  tu- 
mor at  all. 

The  descriptions  given  by  De  Sinety  and  Melassez  of  the  ex- 
ternal surface  of  an  ovarian  cystoma  differ  very  materially  in 
some  points  from  my  own,  but  I  have  only  to  point  to  their 
methods  of  examination  as  affording  a  complete  solution  of  the 
discrepancy.  I  have  already  said — in  a  paper  read  before  the 
Eoyal  Society  upon  the  ''Anatomy  of  the  Umbilical  Cord  " — that 
no  correct  descriptions  can  be  given  of  any  tissue  from  a  micro- 
scopical examination  made  upon  anything  but  perfectly  fresh 
tissue,  and  this  is  most  peculiarly  true  of  an  epithelial  surface. 
To  employ  any  hardening  reagent,  and  then  describe  what  is 
seen,  is,  therefore,  not  describing  what  may  be  seen  in  fresh  tis- 
sue. When  the  French  authorities  say:  '"That  by  employing' 
these  two  processes  we  have  assured  ourselves  that  the  exterior 
investment  of  the  walls  in  no  way  resembles  the  endothelium 
investment  of  the  peritoneum,"  the  difference  between  their  de- 
scription and  mine  is  further  to  be  explained  by  the  different  use 
of  the  term  endothelium.  They  seem  to  employ  it  to  mean  a  sub- 
epithelial layer  of  cells,  while  I  use  it,  on  the  authority  of  Dr. 
Klein,  exclusively  to  mean  the  cells  within  the  stomata ;  and 
while  there  can  be  no  doubt  that  the  subepithelial  arrangements 
are  altogether  different  in  the  ovarian  cystoma  from  those  of 
the  peritoneum,  because  the  structures  are  in  themselves  alto- 
gether different,  the  subepithelial  arrangements  of  an  ovarian 
tumor  are  precisely  those  of  the  ovary. 

Underneath  the  epithelial  layer  which  I  have  just  described 
there  is  a  layer  of  fibrous  stroma  of  varying  thickness,  and  hav- 
ing a  variety  of  structures  in  it.  The  stroma  is  stated  by  differ- 
ent authors  to  be  capable  of  subdivision  into  a  varying  number 
of  layers — from  two  to  six — the  only  point  of  agreement  between 
them  being  that  the  divisions  are  most  marked  at  the  point  of 
implantation  of  the  tumor.     Thus,  De  Sinety  and  Melassez  say: 

"  In  the  neighborhood  of  the  point  of  implantation  may  thus 
be  obtained  three  principal  layers:  one  external,  in  connection 
with  the  peritoneal  cavity;  one  internal,  in  connection  with  the 
cystic  cavity;  and  one  medium,  interposed  to  the  two  preceding. 
The  external  and  internal  layers  have  the  aspect  of  fibrous  mem- 
branes, while  the  medium  layer  has  rather  the  aspect  of  loose 


156  DIsSEASES    OF   THE   OVARIES. 

cellular  tissue.  It  is  in  this  latter  layer  that  the  large  vessels  of 
the  pedicle  spread  themselves  out.  Departing  from  the  base  of 
the  tumor,  the  medium  layer  becomes  thinner,  is  no  longer  isola- 
ble,  and  the  cystic  wall  then  appears  to  be  formed  only  of  two 
fibrous  layers.  Still  farther  toward  the  summit  of  the  tumor  the 
cystic  walls  are  thinner,  and  can  no  longer  be  dissociated  into 
several  layers,  except  by  the  aid  of  a  most  artificial  dissection. 
They  are  no  longer  anything  but  a  fibrous  membrane,  homoge- 
neous in  its  whole  thickness.  These  transformations  are  easily 
explained.  They  are  due  to  the  medium  layer  of  loose  cellular 
tissue  becoming  thinner  and  thinner,  and  finally  disappearing, 
and  to  the  internal  and  external  fibrous  layers  adhering  together 
and  becoming  intimately  blended."' 

Concerning  these  various  statements  I  would  only  say  that  a 
skilful  dissector  could  manage  still  further  to  subdivide  them, 
and  the  results  obtained  in  this  dissection  would,  of  course,  be 
very  materially  influenced  by  the  number  of  diseased  follicles  in 
the  neighborhood  where  he  was  working. 

The  microscopic  structure  of  this  middle  layer  varies  very 
much  with  the  age  of  the  tumor.  In  an  old  example  with  thick- 
ened and  hardened  walls,  more  particularly  if  it  has  been  fre- 
quently tapped,  the  elements  are  almost  entirely  fibrous,  with 
here  and  there  a  few  indications  of  nuclear  arrangements  of  the 
proper  ovarian  stroma,  the  almond-shaped  nuclei  being  often  so 
altered  and  elongated  that  they  are  taken  for  the  rod-shaped  nu- 
clei of  unstriped  muscular  fibre.  I  have,  however,  never  been 
able  to  satisfy  myself  in  a  single  instance  of  the  presence  of  mus- 
cular fibres  in  the  walls  of  an  ovarian  cystoma  ;  while,  on  the 
other  hand,  in  the  parovarian  cyst  it  is  an  almost  uniform  expe- 
rience to  find  muscular  fibre  largely  entering  into  its  constitu- 
tion. Dr.  Grailey  Hewit  has  described  an  ovarian  tumor  with 
muscular  envelope,  but  on  reading  the  account  I  had  no  doubt 
whatever  that  what  he  found  was  a  parovarian  and  not  an  ova- 
rian cystoma.  I  have  myself  seen  a  mass  of  muscular  fibre  in 
an  example  of  the  former  almost  half  an  inch  thick. 

De  Sinet}^  and  Melassez,  however,  speak  of  having  found  a 
great  abundance  of  unstriped  muscular  fibre  in  the  walls  of  an 
ovarian  cystoma,  an  observation  the  results  of  which  are  open 
to  various  explanations.  They  speak  as  a  conclusion  to  be  drawn 
from  their  researches,  that  the  employment  of  ergot  of  rye  may 
have  the  result  of  arresting  the  growth  of  ovarian  cystoma  by 
reason  of  its  power  over  involuntary  muscular  fibre,  and  they 
nctually  quote  a  case  in  which  hypodermic  injections  of  ergotin 
are  supposed  to  have  cured  one.  I  cannot,  however,  assent  to 
anything  which  would  involve  the  application  of  therapeutic  re- 


OVAPwIATT  TUMORS,   OONDITIONS  WIIICII  SIMULATE  THEM.      157 

suits  for  tlie  establishment  of  microscopica]  or  pathological  in- 
vestigations. In  the  words  of  Dr.  Mathews  Duncan  I  may  say 
that  '■'  we  know  of  not  one  single  case  of  cure  of  an  ovarian  cys- 
toma by  any  other  proceeding  than  that  of  the  operation  of 
Ephraim  McDowell." 

In  the  wall  of  a  cyst  of  recent  growth  we  constantly  find  the 
remains  of  normal  Graafian  follicle,  to  which  there  had  not  ex- 
tended the  mysterious  influence  which  directs  cystic  develop- 
ment ;  but  in  an  old  tumor  these  are  not  readily  found,  for  they 
have  either  already  developed  into  cysts,  or  the  advancing  scle- 
rosis has  altogether  destroyed  their  characters.  At  its  base  an 
ovarian  tumor  may  easily  be  separated  from  its  peritoneal  cap- 
sule, just  as  a  normal  ovary  may  be,  and  upon  this  fact  is  based 
the  ingenious  treatment  of  sessile  tumors  by  enucleation,  origi- 
nally suggested  by  Dr.  Miner. 

Among  the  conclusions  made  by  De  Sinety  and  Melassez  is 
one  to  the  effect  that  a  large  number  of  ovarian  cystomata  have 
their  origin  in  the  tubes  of  Pflliger.  Now,  these  tubules  have 
been  the  cause  of  a  great  deal  of  discussion,  and  I,  for  one,  am 
perfectly  satisfied  that  they  have  received  an  amount  of  atten- 
tion, and  have  been  elevated  into  an  importance  they  do  not  de-  « 
serve.  In  Figures  7  and  9  very  fair  representations  of  these 
tubes  are  given,  after  Balfour.  They  are  confined  entirely  to  the 
hilum  of  the  organ,  being,  as  I  have  said,  survivals  of  the  Mal- 
pighian  tubes,  and  therefore  no  part  of  the  true  structure  of  the 
ovary.  I  have  never  yet  seen  them  lined  with  epithelium,  and 
therefore  I  do  not  believe  they  are  capable  of  undergoing  cystic 
development,  for  without  epithelium  I  do  not  think  any  such  pro- 
cess could  occur.  In  all  probability  they  have  some  kind  of  epi- 
thelium in  the  early  stages  of  their  existence,  but  if  they  ever 
had  any  at  all  they  lose  it  in  more  mature  growth.  It  is  possible 
that  in  occasional  instances  they  may  retain  it,  and  then  be  de- 
veloped, just  as  the  tubules  of  the  parovarium;  but  I  have  never 
seen  any  case  in  which  I  had  reason  to  believe  these  tubes  were 
the  origin  of  the  cysts.  If  they  should  give  rise  to  a  cystic  tu- 
mor, one  would  suspect  it  ought  to  be  of  a  unilocular  character, 
and  that  its  walls  would  not  possess  the  features  which  are 
always  characteristic  of  an  adenoid  cystoma. 

In  the  Archives  fiir  Gynekologie,  1870,  Waldeyer  confirms 
this  view  in  a  remarkable  sentence:  "  My  researches  have  de- 
monstrated to  me  that  the  opinion  of  Foster  and  Rindfleisch,  to 
the  effect  that  cystomata  originate  from  the  connective  elements 
of  ovarian  stroma,  is  not  admissible;"  and  with  this  opinion  I 
entirely  agree.  It  will  be  seen,  therefore,  that,  with  the  excep- 
tion of  the  possible  occurrence  of  an  occasional  unilocular  cyst 


158  DISEASES    OF   THE   OVARIES. 

arising  from  the  tubules  of  Pfliiger,  my  belief  is  that  all  ovarian 
cystomata  have  their  origin  in  follicular  dropsy. 

I  have  failed  to  find  any  description  of  a  cartilaginous  growth 
of  the  ovary  apart  from  cystic  alteration,  but  I  have  twice  found 
plates  of  cartilage  in  the  Avails  of  ovarian  cysts,  and  in  neither 
of  these  tumors  were  there  any  other  structures  which  might 
place  them  in  the  category  of  dermoid  cysts.  The  cartilage  was 
composed  of  large  cells  with  very  little  fibrous  matrix ;  in  fact, 
it  was  hyaline  cartilage,  identical  with  what  I  have  seen  repeat- 
edly in  the  testicle.  There  is,  of  course,  no  good  reason  why  en- 
chondromatous  tumors  should  not  be  met  with  in  the  ovary,  just 
as  they  are  in  the  testicle ;  but  in  the  latter  organ  they  occur 
independently  of  cystic  degeneration,  while  I  am  not  aware  that 
they  ever  have  done  so  in  the  ovary. 

Fibromatous  tumors  of  the  ovary  must  be  very  rare,  for  I 
have  only  met  with  three  cases,  and  one  which  was  clearly  malig- 
nant. Growth  of  the  fibrous  stroma  of  the  ovary,  so  as  to  form 
a  large  abdominal  tumor  requiring  removal,  has  not  yet  been 
described,  so  far  as  I  have  been  able  to  discover;  and  under  any 
circumstances  the  condition  is  a  rare  one,  for  Peaslee  has  col- 
lected only  seven  cases,  including  two  which  he  had  seen  him- 
self, and  Atlee  describes  another  which  probably  was  of  this  na- 
ture, though  unfortunately  no  microscopic  examination  of  it  has 
been  recorded.  I  think  that  if  I  had  a  similar  opportunity  now 
of  examining  such  a  preparation,  I  should  be  able  to  give  a  much 
better  account  of  it,  for  I  suspect  that  the  reason  of  its  malig- 
nancy would  be  capable  of  explanation  by  reversion  to  an  imma- 
ture form  of  growth  of  the  cells  of  the  ovarian  stroma,  analogous 
to  that  of  the  cystic  epithelium. 

The  patient  in  whom  occurred  the  first  of  the  tumors  I  am 
about  to  describe  was  forty-four  years  of  age,  was  very  stout,  had 
borne  six  children,  and  had  been  failing  in  health,  owing  to  the 
increasing  size  of  her  abdomen,  for  about  two  years.  She  was 
sent  to  me  by  Dr.  Vinrace  in  July,  1873,  when  I  found  the  abdo- 
men occupied  by  a  large  quantity  of  ascitic  fluid,  in  which  floated 
a  large  and  perfectly  solid  tumor.  The  abdominal  walls  were 
also  very  oedematous.  I  tapped  the  abdomen  and  punctured  the 
skin  repeatedly  with  a  lancet  to  get  quit  of  the  anasarca.  This 
was  repeated  several  times,  until  it  was  evident  that  only  the 
removal  of  the  tumor,  which  I  had  diagnosed  to  be  solid  ovarian, 
would  permanently  benefit  the  patient.  When  the  abdomen  was 
opened,  it  was  found  necessary  to  extend  the  incision  eight  centi- 
metres above  the  umbilicus,  in  all  nearly  twenty-five  centimetres, 
before  the  tumor  could  be  removed.  It  had  an  adhesion  to  a  coil 
of  intestine,  and  a  very  extensive  adhesion  to  the  great  omen- 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      159 

turn,  and  it  occupied  exactly  the  relations  of  the  left  ovary,  the 
other  being  perfectly  healthy.  Its  pedicle  was  clamped,  and  the 
wound  closed  in  the  usual  way.  The  patient  died  on  the  fifth 
day,  as  was  usual  when  the  clamp  was  employed.  The  tumor 
was  round,  smooth,  and  of  a  creamy  white  color,  and  it  weighed 
almost  nine  pounds.  When  cut  into,  it  had  a  glistening,  white, 
and  trabeculated  structure;  and  it  was  perfectly  solid  throughout, 
there  being  no  indication  anywhere  of  cystic  formation.  A  num- 
ber of  very  thin  sections  were  made,  and  these  were  treated  by 
various  processes,  their  uniform  result  being  to  show  that  the  tu- 
m.or  really  was  the  ovary,  and  that  its  overgrowth  was  limited  to 
the  fibrous  stroma.  The  fibres  were  ranged  in  bands  which 
crossed  in  all  directions,  and  treatment  by  acetic  acid  showed 
that  a  few  of  these  bands,  or  perhaps  I  should  say  a  very  few, 
were  composed  of  muscular  fibres,  an  observation  which  substan- 
tiates that  of  Sangali,  quoted  by  Virchow,  made  in  a  similar  but 
much  smaller  tumor.  Looking  at  my  sections  of  this  tumor, 
made  nearly  ten  years  ago  by  the  rough  processes  in  use  before 
I  had  introduced  the  method  of  cutting  sections  of  fresh  frozen 
tissue,  I  cannot  make  out  very  much  more  now,  but  I  feel  nearly 
satisfied  that  these  fibres  are  but  the  result  of  immature  fibre-cell 
growth  running  to  riot.  Throughout  the  tumor,  but  chiefly 
toward  its  surface,  a  number  of  minute  cavities  were  observed, 
lined  by  epithelium,  and  having  in  one  or  two  instances  a  large 
cell  with  a  nucleus,  presenting  all  the  appearances  of  an  ovum. 
The  number  of  these  cavities  in  a  less  pronounced  condition  was 
very  large,  and  I  have  no  doubt  they  were  immature  Graafian 
follicles.  I  have,  within  the  last  few  days,  removed  an  exactly 
similar  tumor  of  smaller  size.  The  pedicle  was  ligatured,  and 
the  patient  recovered  as  usual  without  any  difficulty. 

A  Microscopical  Committee  of  the  Philadelphia  County  Medi- 
cal Society  reported  as  follows  on  a  tumor  of  a  similar  kind,  sub- 
mitted to  them  by  Dr.  Washington  L.  Atlee,  and  which  he  had 
successfully  removed  in  1876: 

"  Thin  sections  from  both  the  fresh  tumors  and  from  hardened 
preparations  exhibited  a  dense,  fibrous-looking  stroma,  in  which 
the  spindle-cells  apparently  constituted  but  a  small  portion,  the 
large  majority  having,  it  seemed,  been  developed  into  the  fully 
formed  fibrous  tissue  which  gave  its  firm,  dense  character  to  the 
growth.  The  application  of  diluted  acetic  acid  brought  into  view 
small  oval  nuclei,  arranged  with  considerable  regularity  in  the 
section,  and  which,  even  under  a  high  power  (1,250  diameters), 
displayed  none  of  the  double,  triple,  and  multiple  character  com- 
monly met  with  in  neoplasmata  of  the  more  malignant  type. 

' '  Your  committee,  therefore,  conclude  that  these  two  ovarian 


160  DISEASES    OF   THE    OVARIES. 

tumors  are  the  spindle-celled  sarcomata  of  Wagner,  Virchow, 
Rindfleisch,  and  other  late  German  pathologists,  and  accurately 
correspond  with  those  described  by  Rokitansky  as  '  Fibrous  Can- 
cer,' and  by  Paget  under  the  name  of  'hard  cancer  with  fibrous 
structure. " 

''According  to  Rokitansky,  ovarian  growths  of  this  charac- 
ter occur  very  rarely,  and  Scanzoni  states  that  these  '  fibrous 
bodies '  of  the  ovary  had.  to  his  knowledge,  only  been  proved  to 
exist  in  four  cases,  up  to  the  time  his  work  was  revised,  in  1858." 

I  have  never  met  with  that  rare  variety  of  fibroma  of  the 
ovary,  of  which  only  three  instances  have  been  described — two 
by  Rokitansky  and  one  by  Klob — and  in  which  small  fibrous 
growths  arise  from  the  corpus  luteum. 

In  the  "Transactions  of  the  Obstetrical  Society  of  London," 
for  1874,  Dr.  Goodhart  relates  a  case  of  fibroma  of  the  ovary. 
l)robably  of  this  kind,  in  a  woman  aged  forty-two,  who  died  from 
granular  disease  of  the  kidneys.  She  had  several  fibrous  tumors 
in  the  uterine  wall,  etc.,  as  well  as  one  in  the  ovary,  which  was 
about  one  and  one-half  inch  in  diameter.  The  relations  of  the 
tumor  were  accurately  determined.  It  grew  directly  from  the 
free  or  epithelial  surface  of  the  organ,  and  had  no  connection 
with  the  broad  ligament.  On  section  it  was  shown  to  spring 
from  the  outer  layer  of  the  ovarian  stroma — that  part  character- 
ized as  "tunica  albuginea  "  by  old  writers,  and  as  the  condensed 
external  layer  of  the  proper  ovarian  stroma  by  Waldeyer. 

The  case  of  malignant  fibroma  was  one  which  I  saw  in  Octo- 
ber, 1869,  in  consultation  with  Dr.  Hollings,  of  Wakefield.  She 
had  a  large  oval  tumor,  solid,  hard,  and  smooth,  moving  freely 
in  the  abdomen,  centrally  situated,  with  a  similar  smaller  one  to 
the  right  side.  The  larger  tumor  reached  about  two  inches  above 
the  umbilicus,  could  be  felt  high  in  the  pelvis,  and  had  an  attach- 
ment to  the  uterus.  I  diagnosed  it  as  a  case  of  solid  cancer  of 
the  ovary,  and  declined  to  operate.  The  abdomen  was  free  from 
ascites  or  other  complication.  I  saw  her  a  second  time  in  a  few 
weeks,  and  found  that  the  tumors  had  both  increased  in  size, 
and  then,  having  made  myself  more  familiar  with  the  subject,  I 
gave  it  as  my  opinion  that  it  was  an  instance  of  the  rarest  of  all 
forms  of  cancer — the  fibroid.  On  December  5th  I  found  her  with 
symptoms  of  peritonitis,  and  a  considerable  effusion  of  ascitic 
fluid.  I  tapped  h(>r,  to  relieve  th(^  breathing,  and  found  a  large, 
soft,  semi-fluctuating  mass  extending  from  near  the  xiphoid  car- 
tilage to  within  three  inches  of  the  pubis,  masking  the  outlines 
of  the  tumors.  This  I  recognized  as  possibly  a  fungoid  growth 
of  the  omentum.  I  tapped  her  again  on  the  0th,  and  she  died 
next  day.     Twenty-four  liours  after  death  I  examined  the  body» 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      IGl 

and,  on  opening  the  abdomen,  I  found  adhesions  everywhere  to 
the  large,  deep-colored  fungous  mass  which  I  had  correctly  re- 
garded as  growing  from  the  omentum.  It  was  adherent  behind 
to  the  intestines  and  to  the  tumors.  The  larger  of  these  latter 
was  found  to  be  perfectly  loose,  save  from  the  omental  mass  and 
the  right  corner  of  the  uterus,  to  which  it  was  attached  by  a 
short,  thick  pedicle;  in  fact,  it  was  the  right  ovary,  as  no  other 
trace  of  the  gland  could  be  found.  The  smaller  tumor  was  simi- 
larly the  left  ovary,  and  a  still  smaller  tumor  seemed  to  grow 
from  the  same  pedicle.  Scattered  over  the  surface  of  the  peri- 
toneum were  patches  very  similar  to  those  previously  described 
as  papillary  cancer  of  the  peritoneum.  These  patches  were  also 
found  on  the  surfaces  of  the  tumors,  and  were  stripped  easily 
off  with  their  investing  epithelial  coverings.  In  the  right  or 
largest  tumor  were  a  few  cavities  containing  fluid,  and  also 
some  curious  cretification  at  the  base  and  in  the  pedicle.  It 
weighed  probably  twelve  or  thirteen  pounds,  so  that  I  could  not 
remove  it  conveniently  for  preservation.  I  removed  and  care- 
fully examined  the  smaller  tumors,  some  peritoneum,  with  speci- 
mens of  the  patches  and  a  piece  of  the  omental  fungus. 

In  the  piece  of  omentum  nothing  but  blood-detritus,  a  few 
scant  fibres,  and  numbers  of  irregular  cells  were  found,  with  im- 
mense numbers  of  free  nuclei,  or  what  seemed  to  be  such.  The 
nodules  on  the  peritoneum  showed  all  the  characters  of  cancer- 
ous tissue,  being  composed  of  large,  irregularly  shaped  and 
irregularly  sized  cells,  containing  variously  shaped  nuclei  in 
varying  numbers.  There  seemed  to  be  no  fibrous  tissue  in  them. 
at  all,  and  their  elements  readily  separated  by  gentle  pressure 
between  the  cover  and  the  glass  slide.  A  careful  section  showed 
the  epithelium  of  the  free  surface  of  the  peritoneal  layer  to  be 
undergoing  interesting  changes.  The  cells  of  the  upper  layer 
were  normal,  but  at  two  or  three  layers'  depth  they  were  seen  to 
be  larger,  more  irregular,  and  the  number  of  nuclei  increased, 
the  latter  fact  being  most  clearly  displayed  on  the  addition  of 
acetic  acid. 

The  ovarian  tumors  removed  were  ovoid,  sinooth,  and  glis- 
tening, and  here  and  there  the  surfaces  were  marked  with  the 
peculiar  patches  above  described.  Together,  they  weighed 
nearly  three  pounds.  When  cut  into,  no  juice  exuded  from 
them,  and  the  scant  moisture  scraped  from  the  cut  surface 
showed  no  cells.  The  tissue  was  pearly  white  and  very  tough. 
Teasing  with  needles  did  not  give  any  satisfactory  results,  and 
a  great  many  sections  had  to  be  made  before  one  thin  enough 
for  examination  was  obtained.  I  then  found  that  the  texture 
was  purely  fibrous,  there  being  nowhere,  under  the  epithelial 
11 


162  DISEASES    OF   THE   OVARIES. 

layers,  any  cells  discoverable.  The  fibres  were  extremely  fine, 
closely  and  regularly  packed,  without  any  appearance  of  undu- 
lation or  interweaving,  but  seemed  to  lie  parallel,  with  only  faint 
curvings  in  their  general  direction.  They  were  readily  stained 
by  carmine.  Acetic  acid  showed  no  nuclei,  and  did  not  influence 
the  fibres  beyond  a  slight  clearing  of  the  section.  The  tumors 
differed  quite  from  those  already  described  as  fibroma,  which  do 
not  seem  to  be  malignant. 

It  will  be  found  that  this  description  differs  in  some  important 
particulars  from  that  given  by  Sir  James  Paget  of  similar  struc- 
tures, especially  in  the  absence  of  nuclei ;  but  the  rarity  of  op- 
portunities for  the  examination  of  such  peculiar  growths  stands 
much  in  the  way  of  their  proper  investigation;  and  now  we  have 
much  better  methods  of  examining  such  growths,  so  that  future 
experience  will  give  far  more  precise  results. ' 

Among  all  the  tumors  I  have  examined  I  have  never  seen 
any  of  the  so-called  osteomata;  indeed  it  is  greatly  to  be  doubted 
if  any  true  osteoma  has  ever  been  found  in  the  ovary,  except  as 
part  of  a  dermoid  cyst.  All  the  others,  of  which  I  have  seen  de- 
scriptions, are  evidently  only  instances  of  cretification. 

This  form  of  change  has  been  very  carefully  studied  by  De 
Sinety  and  Melassez,  and  they  summarize  their  conclusions  as 
follows: 

It  is  presented  in  two  forms,  of  which  the  first  and  more  sim- 
ple consists  of  a  deposit  of  small  calcareous  grains  in  the  con- 
nective substance.  Occasionally  these  appear  deposited  in  the 
interstices  of  two  lamellae  or  two  connective  fasciculi,  in  the 
place  occupied  by  the  connective  cells;  but  that  is  only  an  ap- 
pearance due  to  the  calcification  having  commenced  upon  one 
of  the  faces  of  the  lamella  or  connective  fasciculus.  These  little 
grains  of  calcification  are  sometimes  isolated,  and  sometimes 
united  in  a  band.  This  form  rarely  exists  alone;  it  is  habitually 
met  Avith  associated  with  the  second,  of  which  it  appears  to  be 
the  origin. 

The  second  form  consists  of  more  or  less  extensive  patches, 
disposed  parallel  to  the  cystic  surface.  As  we  have  already 
said,  there  usually  exists  a  layer  of  connective  tissue  between 
them  and  the  cystic  cavity.  Their  internal  or  cystic  surface  is 
generally  smooth,  and  forms,  upon  sections,  a  rectilinear  line; 
while  the  external  or  deep  face,  and  especially  the  extremities, 
are  irregular,  and  present  excrescences  or  depressions.  The  ex- 
crescences have  almost  always  a  rounded,  semi-spherical  form, 
as  if  due  to  the  addition  of  little  calcareous  grains  to  the  princi- 


'  Wilson  Fox  has  noticed  these  degenerations  of  vegetations  (loo.  cit. ,  p.  268). 


OVARIAN  TUMOES,  CONDITIONS  WHICH  SIMULATE  THEM.      163 

pal  mass.  The  depressions  are  in  the  form  of  cupolse,  rather  like 
those  presented  by  bones  attacked  with  atrophic  osteitis;  they 
are  sometimes  situated  in  the  interior  of  the  calcareous  patch, 
and  there  form  very  irregular  anf ractuosities.  In  the  substance 
of  the  patch  may  be  discovered,  further,  the  disposition  of  the 
lamellae  and  connective  fasciculi,  fine  striae  indicating  the  place 
occupied  by  the  connective  cells  now  destroyed. 

Besides  the  formation  of  cystoma  of  the  ovary  from  simple 
distention  of  the  Graafian  follicle  by  an  excess  of  its  proper  fluid, 
Rokitansky  and  Arthur  Farre  long  since  drew  attention  to  the 
formation  of  ovarian  cysts  by  hemorrhage  into  the  cavity  of  the 
follicle.  In  his  classic  article  on  the  ovary  in  the  "  Encyclopedia 
of  Anatomy  and  Physiology,"  Dr.  Farre  figures  and  describes 
such  a  cyst  as  having  "its  cavity  filled  with  loose  flocculi,  of  a 
dark  chocolate  color,  consisting  of  decomposed  blood-clot  mixed 
with  patches  of  membrana  granulosa.  The  walls  of  the  follicle 
were  not  yellow,  and  contained  no  oil-globules,  and  they  were 
slightly  thicker  than  those  of  the  healthy  follicle."  Their  com- 
ponent tissues  were  precisely  those  he  describes  as  characteriz- 
ing the  ovisac  in  its  normal  condition,  and  the  main  bulk  of  its 
structure  was  made  up  of  granules  and  embryonic  fibres,  inter- 
mixed with  a  few  developed  fibres  of  ordinary  white  fibrous  tis- 
sue. He  considers  it  to  constitute  one  of  the  early  stages  of 
these  enormous  growths,  forming  an  ordinary  cystoma  of  the 
ovary. 

Rokitansky  regards  these  cysts  as  being  due  to  a  cystic  de- 
generation of  the  corpus  luteum.  He  says  they  may  exceed  the 
size  of  a  walnut,  that  their  interior  surface  is  wrinkled,  and  their 
exterior  limit  is  easily  recognized. 

Cruveilhier  speaks  of  ovarian  haematic  cysts  as  a  consequence 
of  an  apoplexy  of  the  ovary,  and  as  a  probable  consequence  of 
an  exaggeration  of  the  small  clot  of  blood  produced  in  the  ovary 
at  the  rupture  of  an  ovisac.  These  he  says  are  often  transformed 
into  perfectly  organized  serous  cysts,  of  which  the  origin  is 
sometimes  of  very  doubtful  determination,  though  it  may  be  re- 
vealed by  fibrous  concretions  within  them  or  by  the  orange  yel- 
low coloration  of  their  walls.  The  largest  he  had  seen  was  in 
the  ovary  of  an  old  woman,  in  which  the  cyst  was  filled  with  a 
dark  brown  matter  having  the  consistence  and  color  of  water 
chocolate.  The  walls  of  the  cyst  were  greatly  injected  and  were 
patched  with  red,  being  infiltrated  with  blood  in  their  thickness, 
but  otherwise  they  presented  the  usual  appearances  of  the  struc- 
ture of  the  tunic  of  the  ovisac. 

De  Sinety  and  Melassez  have  made  similar  observations,  and 
I  can  substantiate  all  that  these  observers  have  noticed  in 


164  DISEASES   OF   THE   OVARIES. 

connection  witli  the  production  of  small-sized  cysts  from  what 
may  be  described  as  an  apoplexy  of  the  ovisac.  I  have  no 
doubt  at  all  that  they  are  the  result  of  excessive  hemorrhage 
into  the  cavity,  occurring  either  at  the  time  of  its  rupture  for 
the  discharge  of  the  ovum,  or  perhaps  occurring  when  the 
ovum  was  not  discharged  as  it  ought  to  have  been.  In  one  case 
I  removed  a  tumor  of  this  kind  on  account  of  persistent  and 
intractable  uterine  hemorrhage.  Before  the  operation,  which 
was  performed  in  187o,  I  regarded  the  patient  as  suffering  from 
hemorrhage  due  to  a  uterine  myoma,  but  when  I  opened  the  ab- 
domen I  found  it  was  a  true  ovarian  tumor,  consisting  of  one 
large  cyst,  and  at  its  base  a  few  small  cavities.  The  large  cyst 
contained  a  dark  purple  material  of  the  consistence  of  putty, 
which  was  evidently  the  remains  of  blood-clot,  the  serum  of 
which  had  been  absorbed;  and  this  material  dried  into  a  brittle 
substance,  exactly  as  blood-clot  does.  The  removal  of  the  tumor 
arrested  the  uterine  hemorrhage  completely,  and  the  patient 
made  an  excellent  and  permanent  recovery.  Unfortunately  at 
that  time  I  was  not  so  conversant  with  the  facts  of  ovarian 
pathology  as  I  now  am,  and  the  tumor  was  not  properly  exam- 
ined, and  tlie  only  note  which  I  possess  of  its  appearance,  be- 
yond what  I  have  already  described,  is  that  on  its  inner  surface 
there  was  a  large  patch  having  an  appearance  as  if  it  were  ul- 
cerated, and  that  this  spot  probably  was  the  source  of  the  hem- 
orrhage. Upon  this  ulcerated  surface  there  was  no  appearance 
of  an  epithelial  layer.  Before  any  conclusion  of  value  can  be 
given  from  these  cases  some  similar  experiences  would  have  to 
be  more  carefully  investigated,  but  I  am  strongly  of  the  belief 
that  this  tumor  was  an  example  of  Rokitansky's  hfBmatic  cyst, 
which  had  reached  a  size  and  an  importance  which  those  struc- 
tures do  not  usually  possess. 

I  think  that  Arthur  Farre's  view  is  probably  correct,  and  that 
when  follicular  dropsy  begins  as  an  apoplexy  this  character  is 
maintained  for  only  a  short  time  in  its  history,  and  that  its  after- 
course  is  that  of  an  ordinary  cystoma.  It  is  quite  likely,  how- 
ever, that  an  occasional  instance  will  be  met  with  where  the  dis- 
tention is  due  to  recurrent  hemorrhage,  and  of  this  I  think  my 
case  was  probably  an  example.  I  cannot  pretend,  however,  to 
explain  why  this  should  be  accompanied  by  the  terrible  uterine 
hemorrhage  from  which  my  patient  suffered;  still  less  can  I  see 
why  the  removal  of  the  tumor  should  completely  arrest  this 
symptom. 

The  tubules  of  which  the  parovarium  is  made  up,  frequently 
contain  a  perceptible  amount  of  fluid,  and  I  have  repeatedly  seen 
them  accidentally  in   post-mortem   examinations,  distended   to 


OVARIAN  TUMOKS,  CONDITIONS  WHICH  SIMULATE  THEM.      165 

the  size  of  beans  or  filbert-niits,  and  have  disregarded  them  as 
^'Wolffian  sacs,"  of  no  pathological  importance.  Some  years 
ago  I  had  occasion  to  make  a  medico-legal  examination  of  the 
body  of  a  woman  far  advanced  in  life,  and  I  fomid  in  her  left 
broad  ligament  a  cyst  as  large  as  an  orange,  filled  with  clear, 
limpid  sermii.  It  was  pressing  upward  and  backward  out  of  the 
pelvis,  the  ovary  being  at  its  lower  and  anterior  aspect,  and  the 
Fallopian  tube  arched  over  its  anterior  surface.  On  the  side  next 
the  uterus  two  smaller  cysts  were  lying  close  to  it,  and,  nearer  still, 
a  very  minute  sac,  which  was  evidently,  from  its  mere  shape,  a 
distended  parovarian  tubule.  The  ovary  was  white,  puckered, 
and  shrivelled,  and  had  not  a  continuous  relation  to  any  of  the 
cysts,  though  it  touched  the  largest  at  its  hilum.  The  Fallopian 
tube  was  normal,  and  had  no  other  relation  to  the  tumors  than 
slight  connection  by  loose  areolar  tissue.  There  was  in  my  mind 
no  doubt  that  this  was  a  pathological  indication  of  value;  for  in 
an  ovariotomy  that  I  had  performed  not  long  before,  I  was  struck 
by  the  fact  that  the  ovary  was  perfectly  healthy  and  separated 
from  the  tumor,  as  was  also  the  tube,  by  a  mesovarium  of  some 
•extent;  in  fact,  I  did  not  do  ovariotomy  at  all  in  the  removal  of 
the  tumor;  for,  in  passing  the  chain  of.  the  ecraseur  round  its 
base,  I  did  not  include  either  the  tube  or  the  ovary,  and  they 
were  both  returned  into  the  abdominal  cavity.  In  the  records 
of  ovariotomies  performed  these  cases  have,  up  till  now,  always 
been  stated  as  ovariotomies,  and  the  ovary  and  tube  associated 
w^ith  the  tumor  have  been  removed  with  it.  Both  the  record  and 
the  removal  of  the  ovary  are  mistaken.  The  operation  is  not  an 
■ovariotomy  at  all,  and  nine  times  out  of  ten  both  ovary  and  tube 
might  easily  be  separated  from  the  tube  and  left,  and  this  prac- 
tice I  now  always  try  to  follow.  It  is  very  curious  that  those 
who  are  crying  out  most  loudly  against  the  unnecessary  removal 
of  ovaries  have  been  in  the  habit  of  pursuing  this  practice  in 
the  case  of  parovarian  tumors,  without  compunction. 

The  result  of  all  my  observations  has  been  that  in  every  truly 
unilocular  tumor  I  have  found  the  ovary  unaffected,  though  on 
several  occasions  I  have  seen  it  stretched  over  the  cyst- wall.  I 
have  three  or  four  times  observed  the  ovary  separated  from  the 
cyst  by  a  more  or  less  distinct  mesovarium,  and  on  one  occasion 
I  found  in  that  fold  some  unaffected  parovarian  tubules,  in  the 
case  of  a  lad}^,  a  patient  of  Mr.  Hall- Wright,  from  whom  I  re- 
moved a  large  unilocular  cyst  about  six  years  ago.  In  another 
instance  the  healthy  ovary  was  left  at  least  an  inch  below  the 
clamp;  and  in  a  third  the  ovary  and  tube  were  found  glued  on 
to  the  cyst,  but  forming  no  part  of  it.  In  this  cyst  the  walls 
-were  extremely  thick,  and  contained  large  quantities  of  involun- 


166  DISEASES   OF  THE   OVARIES. 

tary  muscular  fibre — a  fact  which  I  do  not  think  militates  against 
my  view  that  it  was  of  parovarian  origin;  for  nucleated  muscu- 
lar fibre-cells  exist  in  the  broad  ligament  to  some  considerable 
extent,  and  myomatous  tumors  are  found  occasionally  within  its 
folds. 

The  case  to  which  I  have  alluded  as  presenting  a  tumor  with 
many  cysts,  but  which  ought  to  be  placed  under  the  same  cate- 
gory as  the  unilocular  cysts,  occurred  in  the  person  of  a  lady 
aged  sixty-six.  She  was  a  widow,  having  been  married  forty- 
three  years  before  the  tumor  appeared.  The  menses  had  ceased 
for  nearly  twenty  years,  and  her  youngest  child  was  twenty-five 
years  of  age.  There  was  every  reason  to  believe,  therefore,  that 
the  condition  of  the  cell-growth  of  her  ovaries  would  be  one  of 
very  low  activity.  The  tumor  was  first  discovered  about  five 
years  before  I  saw  her,  and  had  grown  slowly  for  four  years  and 
a  half,  but  with  extreme  rapidity  for  six  months.  The  abdomi- 
nal parietes  were  very  thin,  and  the  percussion-wave  was  com- 
municated with  extreme  and  uniform  rapidity  in  every  direction. 
I  diagnosed,  from  my  former  experience,  that  it  was  a  unilocular 
Wolffian  cyst,  and  that  the  ovary  would,  in  all  probability,  be 
found  uninvolved.  I  was  right  about  the  ovary,  for  that  was 
found,  along  with  the  tube,  almost  undisturbed,  and  not  in  any 
way  involved  in  the  tumor,  the  latter  having  apparently  escaped 
from  between  them  backward  and  upward.  I  had  made  a  mis- 
take, however,  about  the  tumor  being  unilocular,  for  it  was  com- 
posed of  five  or  six  sacs.  The  walls  of  these  were  very  peculiar, 
in  being  of  uniform  thickness,  or  rather  thinness,  for  they  were 
like  tissue-paper,  and  had  no  thickening  toward  the  base  of  the 
tumor,  as  is  always  the  case  in  the  multicystic  adenoid  or  multi- 
f  ollicular  tumor  of  the  ovary.  My  belief  is  that  this  tumor  was  a 
specimen  of  dropsy  of  a  number  of  the  parovarian  tubules  ;  for, 
if  one  alone  may  become  dropsical,  there  can  be  no  reason  why 
a  number  should  not  be  so  coincidently.  My  opinion  has  been 
greatly  strengthened,  however,  by  a  re-examination  of  the  tumor 
for  the  special  investigation  of  one  point  drawn  attention  to  by 
Dr.  Bantock;  that  is,  the  possibility  of  separating  the  outer  or  peri- 
toneal coat  of  the  cyst.  This  can  readily  be  done  toward  its 
base  for  a  short  distance  up  from  the  ovary,  discovering  the  fact 
that  the  gland  and  its  duct  can  be  stripped  off  the  tumor  without 
damaging  its  wall.  The  rapid  growth  during  the  later  periods 
of  its  existence,  however,  seems  to  have  so  stretched  the  walls, 
that,  beyond  two  or  three  inches  from  its  base,  the  peritoneal 
layer  cannot  be  separated  from  the  cyst-wall  proper.  I  have 
quite  satisfied  myself  that  this  case  is  really  one  of  multilocular 
parovarian  tumor ;  and  I  am  confirmed  in  this  view  when  I  find 


OVARIAN  TUMORS,   CONDITIONS  WHICH  SIMULATE  THEM.      167 

that  Dr.  Bantock  refers  to  a  case  of  Mr.  Spencer  Wells's,  which 
was  recognized  as  one  of  bilocular  parovarian  cyst. 

Considering  this,  it  is  a  point  for  investigation  whether  or  not 
the  curious  little  pedunculated  cyst,  representing  the  terminal 
bulb  of  the  Wolffian  tube,  and  generally  known  as  the  organ  of 
Rosenmiiller,  may  not  sometimes  form  a  unilocular  tumor  of 
morbid  size,  and  be  removed  as  an  ovarian  growth.  In  one  case 
I  have  removed  it  during  an  ovariotomy  on  account  of  increase 
in  its  size.  All  these  rudimental  structures  are  lined  with  epi- 
thelium, and  may,  therefore,  conduct  themselves  as  other  struc- 
tures so  provided  are  known  to  do. 

The  diagnosis  of  parovarian  cysts  is  generally  very  easy  to 
the  practised  hand,  for  they  give  a  uniform  and  very  rapid  wave 
of  fluctuation  in  every  diameter  of  the  tumor.  Their  shape  is 
usually  globular,  but  they  do  not  project  into  the  pelvis,  as  is 
very  often  the  case  with  the  minor  cysts  of  an  ovarian  tumor. 
They  very  rarely  give  rise  to  symptoms  of  any  kind,  and  still 
more  rarely  to  any  symptoms  of  urgency.  They  sometimes  grow 
very  rapidly.  I  removed  a  very  large  parovarian  cyst  some 
years  ago  from  a  patient  under  the  care  of  Dr.  Campbell,  of 
Stourbridge,  where  the  fact  was  fully  ascertained  that  the  tumor 
grew  in  less  than  six  weeks.  It  may  happen,  however,  that  all 
the  conditions  of  a  parovarian  cyst  may  be  very  closely  imitated 
by  an  ovarian  tumor,  and  they  are  absolutely  mimicked  by  two 
rare  forms  of  cyst  to  be  afterward  described,  one  of  which  is  a 
development  of  the  occluded  tube  of  the  urachus,  and  the  other 
I  believe  to  be  developed  from  a  wandering  ovum.  The  fluid 
removed  from  these  cysts  is  often  limpid,  of  low  specific  gravity, 
containing  little  albumen.  This,  however,  is  by  no  means  always 
the  case,  for  I  have  removed  many  parovarian  cysts  which 
contained  thick,  gelatinous,  grumous,  or  bloody  fluid,  which  mere 
tapping  would  never  have  led  us  to  suppose  had  been  produced 
in  any  other  cavity  than  that  of  an  ovarian  cystoma.  At  the 
meeting  of  the  Medical  Society  of  Strasburg,  November  15, 1875, 
M.  Koeberle  read  a  paper  on  the  diagnosis  between  ovarian  cysts, 
cysts  of  the  broad  ligament,  and  cysts  of  the  Fallopian  tube, 
based  on  the  chemical  examination  of  the  fluid  contained  in 
them.  He  finds  that  the  fluid  of  ovarian  cysts  contains  some 
albumen,  but  a  much  larger  proportion  of  the  variety  of  albumen 
called  paralbumen,  the  precipitate  of  which  by  nitric  acid  is 
soluble  in  acetic  acid.  The  fluid  found  in  cysts  of  the  Fallopian 
tube,  on  the  contrary,  he  says,  contain  albumen,  but  no  paralbu- 
men, so  that  the  precipitate  formed  by  nitric  acid  is  rather  in- 
creased by  acetic  acid.  The  fluid  of  cysts  of  the  broad  ligament 
is  generally  very  limpid,  containing  salines,  but  no  albumen. 


168  DISEASES    OF   THE   OVAKIES. 

Sometimes,  however,  it  contains  a  small  quantity  of  albumen, 
and  the  precipitate  formed  by  nitric  acid  may  be  soluble  in  an  ex- 
cess of  that  acid.  The  researches  of  Schutzenberger  with  the  tan- 
nin process  for  estimating  the  quantity  and  kind  of  albumen  have, 
however,  thrown  great  doubt  on  these  conclusions,  and  by  the 
same  means  I  have  quite  satisfied  myself  that  M.  Koeberle's  con- 
clusions are  not  to  be  accepted.  At  my  request  my  friend  Dr. 
McMunn,  of  Wolverhampton,  undertook  to  investigate  the  pos- 
sibility of  determining  the  source  of  fluids  by  means  of  the  spec- 
troscope. I  furnished  him  with  a  number  of  specimens  of  fluid, 
the  sources  of  which  were  absolutely  known,  but  the  results  of 
his  researches  were  entirely  negative.  They  are  given  in  detail 
in  his  valuable  work  on  "The  Spectroscope  in  Medicine"  (Lon- 
don, 1880).  There  is  an  impression  abroad  that  these  cysts  are 
occasionally  cured  by  tapping,  but  I  am  bound  to  say  I  have 
never  met  with  an  instance  of  it.  I  have  tapped  many  of  them, 
and  I  have  seen  them  remain  quiescent  for  a  time — as  long  as 
three  3'ears — and  then  require  to  be  tapped  again.  In  my  recent 
practice  I  have  altogether  discontinued  tapping,  and  I  invariably 
remove  them,  the  operation  for  their  removal  being  simple  and 
easy,  and  in  my  hands  it  has  been  uniformly  successful. 

A  further  point  of  great  importance  in  recognizing  mere 
ascites  from  an  ovarian  or  parovarian  tumor,  is  that  in  the  for- 
mer condition  there  is  generally  an  appearance  in  the  patient's 
face  of  suffering  from  serious  functional  disturbance,  whereas 
in  the  latter  the  patient  often  looks  in  perfect  health.  Sometimes 
we  find  the  walls  of  a  parovarian  tumor  very  thin  and  flaccid, 
in  this  way  closeh^  resembling  the  appearance  of  ascites. 

This  class  of  tumors  it  is  which  has  given  rise  to  a  great 
many  different  beliefs  in  connection  with  the  history  and  treat- 
ment of  ovarian  tumors  which  Dr.  Mathews  Duncan  has  very 
properly  designated  delusions.  Among  these  was  the  belief, 
originated  by  M.  Boinet,  that  ovarian  tumors  had  been  cured  by 
tapping,  by  injection  with  iodine,  by  what  Mr.  Baker  Brown 
called  a  formation  of  a  false  oviduct  by  the  insertion  of  setons, 
and  by  a  variety  of  other  more  or  less  barbarous  and  unscientific 
proceedings. 

The  walls  of  these  cysts  are  nearly  always  very  thin,  consist- 
ing of  little  more  than  a  thin  basement-membrane  and  a  lining 
of  columnar  epithelium.  This  epithelium  undoubtedly  undergoes 
alterations  such  as  I  have  described  as  occurring  in  ovarian 
cysts,  for  I  have  seen  all  the  appearances  on  the  lining  of  a  par- 
ovarian cyst  that  I  have  seen  in  an  ovarian  tumor.  They  un- 
dergo malignant  degeneration,  they  su])purate  and  become  gan- 
grenous just  as  ovarian  tumors  do.     Sometimes  the  basement- 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      169 

membrane  of  their  walls,  which  always  contains  some  muscular 
fibre,  becomes  enormously  thickened,  and  I  have  removed  a 
parovarian  cyst  with  walls  more  than  half  an  inch  thick,  the 
greater  part  of  wliich  was  composed  of  fusiform  muscular  cells. 

They  are  therefore  not  matters  to  trifle  with.  Their  early 
removal  is  always  simple  and  safe.  They  should  never  be  tam- 
pered with  by  tapping,  but  ought  to  be  removed  by  abdominal 
section  in  their  early  stages,  just  as  should  ovarian  tumors. 
Sometimes  they  burst  and  seem  to  disappear  spontaneously,  and 
this  again  has  given  rise  to  the  statement  that  this  result  is  ob- 
tained occasionally  for  ovarian  tumors.  When  this  fortunate  ac- 
cident takes  place  early  in  their  history  it  will  probably  do  no 
harm,  but  if  it  occurs  during  the  advanced  stages  it  is  just  as 
likely  to  result  in  cancerous  implantation  of  the  peritoneum  as 
if  the  cyst  had  been  ovarian.  A  few  months  ago  I  removed  a 
large  parovarian  cyst  which  had  several  times  been  tapped,  and 
which  had  ruptured  into  the  abdominal  cavity.  On  removing  it 
I  found  the  peritoneal  surface  studded  with  papilloma,  of  which 
the  patient  has  since  died. 

I  have  now  to  speak  of  that  variety  of  cystoma  to  which  I 
have  frequently  referred  as  "  Rokitansky's  tumor,"  or  the  multi- 
ple cystoma.  I  am  quite  aware  that  both  of  these  names  are 
open  to  objection,  but  I  have  failed  to  find  any  other  more  appro- 
priate or  descriptive.  To  Rokitansky  is  clearly  due  the  credit  of 
having  first  described  the  tumor  as  a  special  variety  of  ovarian 
cystoma,  and  to  Ritchie  must  be  accorded  the  priority  of  discov- 
ering ova  in  its  cysts;  though,  as  I  have  already  shown,  the  ob- 
servation led  him  into  a  too  hasty  generalization.  I  think  that 
I  may  claim  for  myself  the  position  of  having  first  arranged  the 
various  contributions  into  their  proper  positions,  and  from  two 
specimens  I  can  now  confirm  and  extend  the  observations  of  the 
two  authors  I  have  cited. 

These  tumors  are  always  double,  no  case  having  yet  been 
described  as  having  occurred  on  one  side  only.  They  are  always 
of  very  slow  growth ;  their  cysts  are  uniformly  small,  rarely 
reaching  the  size  of  an  orange,  and  generally  being  little  bigger 
than  grapes.  The  tumors  are  never  large,  and  it  is  only  the  fact 
that  both  ovaries  are  always  affected  that  makes  them  objects  of 
surgical  interference.  The  contents  of  the  cysts  are  invariably 
limpid,  and  the  ovum  may  nearly  always  be  found,  and  in  these 
two  respects,  as  well  in  the  immense  number  of  the  cysts,  the 
tumors  differ  absolutely  from  ordinary  cystoma. 

The  first  case  occurred  in  the  person  of  a  hospital  patient  from 
whom  I  removed  both  ovaries.  Both  tumors  were  multilocular, 
and  had  one  or  two  major  with  innumerable  minor  cysts,  gradu- 


170  DISEASES   OF   THE   OVAEIES. 

ating  down  to  the  most  minute  size.  The  fluid  contents  of  all 
were  limpid,  and  what  was  evacuated  from  three  or  four  cysts 
at  the  time  of  the  operation,  together  with  the  solid  masses  of 
both  tumors,  did  not  weigh  quite  ten  pounds.  The  right  tumor 
seemed  to  be  about  one-fourth  larger  than  the  left,  so  that  they 
were  probably  four  and  six  pounds  in  weight  respectively — small- 
sized  tumors.  Both  pedicles  were  included  in  one  clamp,  and 
the  patient  made  an  uninterrupted  recovery. 

After  removal,  the  most  careful  examination  of  the  tumors 
failed  to  discover  any  remnant  of  the  ovaries  outside  them,  nor 
did  I  find  any  trace  of  either  of  the  Fallopian  tubes,  as  I  had  not 
removed  them.  The  tumors  were  pearly  white  and  glistening; 
but  the  thin  parts  of  the  major  cysts  had  a  peculiar  transparency 
that  I  had  never  noticed  in  any  other  tumors  before,  and  colum- 
nar bands  stood  out  here  and  there  in  relief  on  the  walls.  I  may 
say  that  the  tumors  had  been  of  extremely  slow  growth;  for  I 
had  had  the  patient  under  notice  for  nearly  a  year  before  the 
operation,  and  had  not  discovered  any  increase  in  the  size  of  the 
tumors,  though  they  had  been  in  existence  probably  five  or  six 
years. 

The  interiors  of  the  large  cysts  were  lined  with  regular  col- 
umnar epithelium,  and  the  wall  seemed  composed  of  fibrous  tis- 
sue with  some  nucleated  almond-shaped  cells.  The  smaller  cysts 
were  densely  packed  together,  and  at  some  places,  where  they 
were  of  a  uniform  size,  the  tumors  had  much  the  appearance  of 
huge  white  raspberries.  I  was  struck  with  the  resemblance  the 
tumors  presented  to  what  I  recollected  of  those  in  which  Roki- 
tansky  and  Ritchie  had  found  ova,  and  I  at  once  turned  to  Dr. 
Ritchie's  admirable  monograph,  and  found  that  the  tumors  an- 
swered the  descriptions  completely.  I  therefore  examined  the 
contents  of  as  large  a  number  of  the  cysts  as  I  could,  and  in 
every  one — I  think  without  exception — I  found  more  or  less  dis- 
tinct evidence  of  an  ovum. 

It  will  serve  my  purpose  best  to  quote  at  length  from  Dr. 
Ritchie's  book — for  our  experiences  are  almost  identical — and  he 
also  gives  the  observations  of  Rokitansky. 

"  In  the  first  volume  of  the  Wochenhlatt  der  Zeitschrift  der 
K.  K.  Gesellschaft  der  Aerzte  zu  Wien,  Rokitansky  describes 
the  appearances  observed  in  the  post-mortem  examination  of  a 
woman,  twenty-six  years  of  age,  who  died  with  diseased  ovaries. 
Both  ovaries  were  affected.  The  tumor  on  the  right  side  was  as 
large  as  a  child's  head,  that  on  the  left  as  large  as  a  man's  fist. 
Both  ovaries  were  composed  of  a  number  of  cysts  as  large  as  a 
cherry,  which  for  the  most  part  lay  closely  packed  together,  here 
and  there  had  become  flattened  by  mutual  compression,  and  oc- 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      171 

casionally  even  projected  into  each  other.  The  surfaces  of  the 
tumors  were  thus  slightly  lobulated,  and  between  the  protuber- 
ances were  seen,  at  intervals,  cysts  as  large  as  a  barleycorn,  a 
pea,  or  a  bean.  These  latter  cysts,  on  being  punctured,  gave 
exit  to  a  greenish-colored  fluid  containing  membranous  flocculi, 
and  in  all  of  them  the  ovum  was  found.  In  each  of  them,  how- 
ever, the  ovum  was  softened,  very  dull-colored,  easily  disinte- 
grated. The  zona  pellucida  had  for  the  most  part  lost  its  sharp 
contour,  and,  except  in  one  case,  no  germinal  vesicle  was  dis- 
coverable. 

"As  far  as  I  am  aware,  this  observation  of  Rokitansky  was 
never  publicly  confirmed  until  July,  1864,  when  the  reporter  to 
the  Medical  Times  and  Gazette  of  four  cases  of  ovariotomy,  per- 
formed by  Mr.  Spencer  Wells  in  the  Samaritan  Hospital,  men- 
tioned that,  in  two  of  the  tumors  removed.  Dr.  Webb  and  myself 
had  been  fortunate  enough  to  discover  many  ova. 

"  The  patient  from  whom  the  tumors  in  question  were  re- 
moved was  fifty-four  years  of  age,  and  had  been  for  some  time 
suffering  from  double  ovarian  disease.  The  tumors  were  easily 
extirpated,  and  the  patient  recovered.  Each  tumor  was  of  the 
size  of  the  head  of  a  child  four  years  of  age.  Each  contained 
several  large  central  cavities,  and  a  number  of  smaller  ones  in 
the  wall  of  the  central  cavity,  the  wall  itself  never  exceeding 
one  inch  in  thickness.  In  the  Medical  Times  and  Gazette  for 
August  6,  1864,  Mr.  Spencer  Wells  wrote  as  follows: 

"  'The  two  tumors  in  question  were  examined  directly  after 
their  removal  by  Dr.  Ritchie,  who  pointed  out  to  me,  in  each  of 
them,  a  number  of  small  cysts,  which  were  evidently  enlarged 
Graafian  follicles.  Knowing  the  great  and  long  familiarity  which 
Dr.  Woodham  Webb  has  had  with  the  ova  of  various  species  of 
animals  since  his  researches  in  conjunction  with  Barry,  I  asked 
him  to  examine  some  of  the  cysts,  in  order  to  ascertain  whether 
they  did  or  did  not  contain  ova,  knowing  that  on  this  point  no 
higher  authority  could  be  appealed  to. 

"  '  As  one  friend  has  suggested  that  we  may  have  mistaken 
a  blood-corpuscle  for  an  ovum,  there  was  evidently  some  reason 
for  my  caution;  but  I  trust  that  the  following  note  from  Dr. 
Webb  will  set  all  such  doubts  at  rest: 

"  '  "  Both  the  tumors  you  sent  me,  after  their  removal  from  a 
woman  fifty-four  years  old,  were  growths  in  excess  of  true  ova- 
rian structure.  The  multilocular  character  was  produced  by 
clusters  of  ovisacs  of  various  sizes.  Ova,  with  the  other  natural 
contents,  were  to  be  found  in  all  the  small  sacs.  The  fibrous 
coats  of  the  larger  sacs  were  thickened,  and  had  many  other 
secondary  sacs  developed  in  them.     The  interior  was  lined  with 


172  DISEASES   OF   THE   OVARIES. 

epithelium,  which  in  some  instances  had,  by  parthenogenetic 
enlargement  and  successive  budding  of  the  cells,  given  rise  to 
bunches  of  grape-like  growths,  repeated  generations  of  imperfect 
ova." 

"  *  The  whole,  then,  was  nothing  more  than  a  reproduction  in 
the  human  subject  of  conditions  which  are  natural  in  some  of  the 
lower  creatures.  I  suppose  the  description,  in  your  orthodox 
pathological  terms,  would  be,  **  hypertrophy  of  the  ovaries,  with 
arrested  development  of  the  contents."  ' 

"  This  letter,  coming  from  a  gentleman  of  Dr.  Webb's  known 
experience,  is  of  great  interest.  Dr.  Webb  evidently  inclines  to 
the  belief  that  the  ovum  is  only  an  altered  epithelium-cell.  He 
also  seems  to  believe  that  the  grape-like  growths — those  de- 
scribed farther  down  as  dendritic  growths — are  repeated  genera- 
tions of  imperfect  ova."' 

Dr.  Ritchie's  unfortunate  death,  and  my  want  of  acquaintance 
at  that  time  with  Dr.  Webb,  hindered  me  from  becoming  ac- 
quainted with  their  method  of  manipulation;  but  that  which  I 
devised  for  myself  answered  my  purpose  completely.  It  consists 
in  slitting  open  the  cyst  freely  with  a  cataract-knife  over  a  coni- 
cal glass,  collecting  the  whole  contents,  and  afterward  syringing 
out  the  cavity  of  the  cyst  gently  with  a  solution  of  sulphate  of 
magnesia  in  distilled  water  of  a  density  something  near  that  of 
the  cyst  contents.  The  fluid  with  which  the  cyst  is  syringed  out 
is  allowed  also  to  fall  into  the  vessel,  and  the  whole  to  stand  for  a 
few  hours,  at  the  end  of  which  time  a  little  flocculent  sediment 
will  have  collected  at  the  bottom  of  the  vessel.  This  is  to  be 
carefully  lifted  by  a  pipette,  deposited  in  a  clean  watch-glass, 
and  the  ovum  searched  for  under  the  microscope.  What  I  found 
in  every  case  I  could  not,  of  course,  assert  was  an  ovum;  but 
having  found  one  or  two  specimens  about  which  there  could  be 
no  doubt,  and  in  every  case  something  that  was  more  or  less 
like  one,  I  am  perfectly  satisfied  that  in  those  tumors  every  cyst 
was  a  dilated  ovisac.  The  smaller  the  sac,  the  more  perfect  the 
ovum  seemed  to  be,  and  consequently  I  assumed  that  these  Avere 
the  more  recent  growths.  Not  only  were  these  dilated  ovisacs  in 
the  periphery  of  the  tumors,  but  they  were  found  throughout  its 
substance.  In  fact,  it  seemed  to  me  as  if,  for  a  long  period  of  lier 
ovarian  histoi-y,  the  ova  had  been  garnered  up  in  cysts  instead 
of  being  shed  in  the  usual  manner.  Her  youngest  child  was  six 
years  old,  and  if  we  were  to  assume  that  an  ovum  is  shed  from 
each  ovary  monthly,  then  we  should  get  the  number  of  ova  so 
retained  as  about  one  hundred  and  fifty.  The  number  of  cysts 
was,  however,  much  greater,  probably  two  or  three  times  as 
many;  so  that  we  may  choose  between  two  explanations — either 


OVAMATs^  TUMORS,  CONDITIONS  WHICH  SIMULATE  TPIEM.      173 

that  the  tumors  had  existed  before  her  last  pregnancy,  or  that 
more  than  two  ova  are  shed  in  the  month.  My  own  behef  is, 
that  both  these  suppositions  are  correct;  for,  when  speaking  of 
ovulation  at  the  beginning  of  the  essay,  I  gave  reasons  for  my 
belief  that  ovulation  and  menstruation  had  only  a  connection  of 
concurrence.  I  am  of  opinion  that  ovulation  takes  place  far 
more  frequently  than  menstruation  does. 

It  is  a  somewhat  singular  fact  that  the  observation  of  Roki- 
tansky  has  not  been  confirmed,  as  far  as  I  have  yet  seen,  by  any 
others  than  Ritchie  and  Webb,  and  by  my  own  cases.  Still 
more  curious  is  it  that  all  four  cases  are  almost  identical,  pre- 
senting small  multilocular  tumors  of  slow  growth,  and  that  in 
all  four  cases  both  ovaries  w-ere  affected.  This  inclines  me  to 
believe  that  in  these  cases  we  have  to  deal  with  a  special  kind  of 
ovarian  tumor,  occurring  rarely  and  differing  from  the  ordi- 
nary adenoid  growth.  Whether  this  be  so  or  not,  further  expe- 
rience alone  can  show.  Dr.  Ritchie  says,  immediately  following 
the  quotation  I  have  given  above,  that  he  subsequently  suc- 
ceeded in  finding  ova  in  some  of  the  loculi  of  a  large  number  of 
ovarian  cysts,  but  never  in  a  loculus  larger  than  a  cherry,  nor 
in  one  that  had  jelly-like  contents.  This  observation  I  cannot 
confirm;  for,  though  I  have  made  many  searches  in  the  endo- 
genous and  subjacent  secondary  cysts  of  ordinary  polycystic 
tumors,  I  have  never  found  an  ovum  or  anything  resembling 
one.  Perhaps  my  method  is  defective.  Dr.  Ritchie  further 
says  that,  when  no  ovum  is  to  be  found,  a  single  minor  cyst  iS' 
to  be  seen,  embedded  in  one  part  of  the  wall,  and  he  has 
thought  himself  justified  in  concluding  that  this  appearance 
represents  dropsy  of  the  blastodermic  vesicle.  I  have  certainly 
seen  such  vesicles  in  the  walls  of  small  cysts,  but  I  have  as  often 
found  them  multiple  as  single,  and  I  have  never  seen  reason  to 
interpret  them  as  Dr.  Ritchie  has  done. 

The  second  case  of  the  occurrence  of  this  peculiar  form  of 
tumor  was  that  of  a  patient  sent  to  me  by  Dr.  McVeagh  of 
Coventry  in  December  last.  The  tumor  had  been  noticed  for 
two  years,  and  had  been  increasing  somewhat  rapidly  for  seven 
months.  I  had  no  doubt  as  to  the  diagnosis  of  an  ovarian 
tumor,  but  there  was  something  in  the  examination  that  made 
me  fear  it  was  malignant.  The  patient  was  thin  and  looked 
very  ill,  but  yet  had  no  particular  symptoms,  and  the  distention 
of  the  abdomen  was  not  great — that  is,  the  tumor  was  not  very 
large.  I  operated  on  December  Ttli,  and  when  I  opened  the  ab- 
domen I  found  a  large  mass  of  glistening  cysts  of  a  pearly  Avhite 
lustre,  var^dng  in  size  from  a  pea  to  a  small  orange.  The  omen- 
tum was  inextricably  mixed  up  with  them,  so  that  at  first  sight 


174 


DISEASES   OF  THE   OVARIES. 


I  was  under  the  impression  I  had  made  a  mistake  and  had  to 
deal  with  a  case  of  hydatids  of  the  peritoneum.  I  found,  how- 
ever, that  tlie  mass  was  removable  and  that  the  cysts  were  pe- 
diculated  upon  a  common  stem.  To  get  the  mass  out  of  the  ab- 
domen was  a  matter  of  no 
small  difficulty,  and  to 
accomplish  it  I  had  to 
make  an  unusually  large 
incision,  nearly  seven 
inches  long.  Then  I  found 
that  the  stalk  of  the  tumor 
reached  toward  the  left 
cornu  of  the  uterus,  and 
that  as  the  left  ovary  could 
nowhere  be  found  the  tu- 
mor must  represent  it.  I 
tied  the  pedicle  and  re- 
moved the  mass ;  I  then 
looked  for  the  right  ovary, 
but  could  nowhere  find  it, 
but  loose  in  the  abdomen 
I  found  a  smaller  mass  of 
cysts  which  I  think  must 
have  been  the  missing 
gland.  How  it  came  to  be 
separated  from  its  stalk  I 
do  not  know.  During  the 
operation  several  of  the 
cysts  had  become  detached 
from  the  common  stem  by 
rupture  of  the  slender  peti- 
oles, and  I  had  to  hunt 
carefully  about  among  the 
intestines  to  make  sure 
that  I  left  none  of  them. 
The  patient  made  an  excel- 
lent recovery,  and  is  now 
in  perfect  health. 

The  adjoining  illustra- 
tion, which  is  taken  from 
a  photograph,  will  give  a  better  idea  of  the  appearance  of  the 
tumor  than  any  description.  On  the  right  side  and  hanging  down 
from  the  mass  may  be  seen  the  omentum,  nearly  the  whole  of 
which  was  removed  with  the  tumor,  and  through  the  meshes  of 
which  many  of  the  cysts  seem  to  have  grown.     It  is  adherent 


Fio.  28. — RokitariKky's  Tumor,  eneh  cyst  containing  an 
ovum :  from  a  photopraph  by  Thrupp.  nhont  one-third  of 
actual  size.  Treparation  ni  Hiiiitfriiin  Museiiin  of  Royal 
College  of  Burgeons. 


OVAEIAN  TUMOES,   CONDITIONS  WHICH  SIMULATE  THEM.      175 

here  and  there,  but  its  association  with  the  tumor  seems  to  be 
more  that  it  is  involved  vs^ith  the  growth  in  a  sort  of  mesh-work, 
than  as  having  the  ordinary  form  of  adhesion.  Everywhere  the 
curious  small  cysts  with  their  slender  pedicles  may  be  seen  hang- 
ing like  grapes  upon  their  stalks,  and  at  the  upper  part  of  the 
tumor  may  be  seen  some  of  these  pedicles  branching  and  having 
cysts  attached  to  them  exactly  like  leaves  upon  their  stalks.  In 
this  respect  it  differs  somewhat  from  the  first  case  I  have  de- 
scribed, but  at  other  parts  of  the  tumor  the  resemblance  is  close, 
and  microscopical  investigations  gave  exactly  the  same  results  as 
those  above  described.  Save  in  the  very  largest  cavities  which 
had  been  emptied  in  order  to  facilitate  the  removal  of  the  tumor, 
I  found  a  normally  columnar  epithelium,  and  normal  or  nearly 
normal  ova.  In  the  small  cysts  the  appearances  were  precisely 
those  seen  in  Graafian  follicles.  The  tumor  is  now  in  the  mu- 
seum of  the  College  of  Surgeons,  and  I  trust  that  any  one  meet- 
ing with  a  similar  example  will  secure  for  it  a  most  careful  ex- 
amination. 

Partaking  of  the  nature  of  the  cysts  last  described,  to  some 
extent  and  in  some  way  yet  inexplicable,  are  the  mysterious  pro- 
ductions known  as  dermoid  cysts.  The  term  "  dermoid"  is  not 
a  good  one,  for  it  by  no  means  gives  expression  to  a  constant 
character  of  these  tumors.  Sometimes  there  is  no  trace  of  any 
epithelial  products  at  all;  while  we  find  bones,  muscle,  and 
brain-substance  even,  according  to  Beneke,  in  some  of  them. 
The  name,  however,  is  hallowed  by  tradition,  and  it  is  not  easy 
to  coin  a  better  one. 

I  have  already  explained  at  some  length,  and  I  hope  success- 
fully, my  view  that  Rokitansky's  tumor  is  produced  by  the  re- 
tention of  the  ova  in  the  Graafian  follicles  and  the  distention  of 
their  cavities  by  a  continuous  secretion  of  the  liquor  folliculi. 
My  theory  of  the  production  of  dermoid  tumors  is  that  they  are 
the  result  of  a  growth  of  the  ovum  itself. 

That  these  tumors  are  the  result  of  change  in  an  ovum  is 
about  the  only  part  of  their  history  regarding  which  there  can 
be  any  certainty.  But  there  may  be  doubt  as  to  whether  the 
abnormality  takes  origin  in  an  ovum  of  the  individual  bearing 
the  tumor,  or  in  the  ovum  from  which  she  herself  was  developed; 
in  other  words,  whether  the  tumors  are  abnormally  developed 
ova  or  are  due  to  inclusion.  That  they  have  any  origin  in  im- 
pregnation, we  may  at  once  dismiss  as  excluded  from  serious 
consideration,  since  they  have  been  frequently  found  in  newly 
born  children,  and  their  most  common  seat  is  in  the  ovaries  of 
young  women,  chiefly,  according  to  Mr.  Spencer  Wells,  of  fair 
complexion. 


176  DISEASES   OF   THE  OVARIES. 

The  question  of  their  origin,  then,  lies  between  the  hypothe- 
sis of  an  effort  on  the  part  of  some  over-active  ovum  in  the  di- 
rection of  partlienogenesis,  which  has  been  based  by  Dr.  Ritchie 
on  Blumenbach's  less  scientific  and  more  scholastic  expression 
of  "  excess  of  formative  nisus,"  and  the  equally  hypothetical 
process  of  inclusion.  As  far  as  we  know  anything  about  inclu- 
sion, it  follows  the  usual  law  of  teratology,  that  any  attached 
individual,  whether  developed  or  blighted,  is  symmetrically  con- 
nected. Thus  the  Siamese  Twins  and  the  Millie-Christie  mon- 
strosity have  the  attachment  in  similar  and  identical  structures, 
the  one  to  the  other  (see  Vrolik,  Von  Baer,  etc.).  I  have  seen 
nowhere  on  record  that  any  fetal  remains  have  been  found  at- 
tached to  an  ovary'  or  situated  in  an  ovary  in  any  way  which 
could  find  them  a  classification  under  this  law.  The  tissues  met 
with  are  always  rudimental,  and  such  as,  while  they  are  the 
product  of  the  ovum  after  conception,  have  no  anatomical  anal- 
ogy whatever  to  tlie  tissues  of  the  ovary.  I  am  disposed,  there- 
fore, to  set  aside  entirely  the  view  of  their  origin  by  inclusion, 
as  the  ovary  is  about  the  most  unlikel}'  structure  in  the  embryo 
for  such  a  process;  and,  if  they  had  their  origin  in  such  a  way, 
we  ought  to  find  dermoid  cysts  in  the  testicles  of  the  male  quite 
as  often  as  in  the  ovaries  of  women. 

There  is  only  left,  then,  the  explanation  that  dermoid  cysts 
are  the  result  of  an  altered  nutrition  of  one  or  inore  ova;  and,  if 
I  may  lay  down  a  dogma  from  my  own  dissections,  I  should  say, 
of  one  ovum  only.  Dermoid  cysts  are  generally  unilocular,  and, 
when  they  are  not  so,  it  is  not  difficult  to  show,  as  has  been 
done  by  Dr.  Ritchie,  and  has  been  evident  in  one  or  two  speci- 
mens that  I  have  examined,  that  tlie  secondary  cysts  are  formed 
by  the  mother  cyst  being  partitioned  off  by  the  growth  of  ridge- 
like walls  on  the  inside  of  the  cyst. 

The  occurrence  of  cysts  having  a  structure  somewhat  re- 
sembling the  dermoid  cysts  of  the  ovary  in  other  parts  of  the 
body,  especially  in  the  neighborhood  of  the  orbit,  has  led  to  con- 
fusion in  the  discussion  of  the  origin  of  the  ovarian  cysts.  In 
the  orbital  cysts  we  have  only  aberrations  of  the  normal  process 
of  the  involution  of  epithelium  from  which  the  structures  are 
developed,  and  there  is  no  mention,  as  far  as  I  can  find,  of  tliese 
extremely  ^mall  congenital  cysts,  which  never  enlarge  in  after 
life,  having  l)een  found  to  contain  anything  but  purely  epithelial 
jjroducts,  such  as  hair,  dead  epithelial  cells,  and  fat.  In  dermoid 
cysts  of  the  ovary,  however,  the  variety  of  products  is  so  great, 
as  to  put  all  analogy  between  them  and  inclusive  cysts  out  of 
the  possibilities.  Thus,  in  one  ovarian  cyst  which  I  examined 
under  the   direction    of  my  friend   and   teacher.  Dr.  Grainger 


OVAEIAN  TUMOKS,  CONDITIONS  WHICH  SIMULATE  THEM.      177 

Stewart,  many  years  ago,  in  the  substance  of  a  wall  between 
two  loculi,  were  spread  out  flat  bones  which  were  undoubtedly 
some  of  the  bones  of  the  skull,  and  near  them  could  be  felt  the 
representatives  of  the  bones  of  a  limb  arranged  in  order.  True 
bone  is  frequently  found  in  ovarian  cysts,  and  often  in  those 
that  have  no  dermoid  structures  at  all. 

Sir  James  Paget  refers  to  a  remarkable  specimen  in  the  mu- 
seum of  St.  George's  Hospital,  which  exhibits  a  mass  of  fatty 
matter  and  a  lock  of  dark  hair,  one  and  a  half  or  two  inches 
long,  attached  to  the  inner  surface  of  the  dura  mater  at  the  tor- 
cular  Herophili,  found  in  a  child  two  and  a  half  years  old,  in 
whom  it  appeared  to  be  congenital.  He  adds,  in  a  foot-note, 
that  Dr.  John  Ogle,  who  had  carefully  examined  the  specimen 
and  described  it  to  the  Pathological  Society,  was  of  opinion  that 
the  cyst  was  originally  of  extracranial  formation,  but  that,  at  an 
early  period  of  fetal  life,  before  ossification  of  the  occipital  bone 
had  taken  place,  the  cerebral  membranes  and  scalp  had  become 
adherent,  and  that,  as  the  development  of  the  bone  went  on,  the 
outer  integument  was  drawn  in  by  retirement  of  the  cerebral 
membranes.  In  this  way  some  of  the  cutaneous  structures  had 
become  included  within  the  cranium.  He  considers  that  the 
cyst  possesses  characters  which  warrant  the  above  supposition, 
and  he  adds  that,  in  a  simila^  manner,  cysts  within  the  orbit 
may  extend  into  the  cranial  cavity.  No  such  explanation  could 
include  the  phenomena  of  the  ovarian  tumors  which  contain 
such  structures  as  teeth,  bone,  cartilage,  striped  muscular  fibre, 
brain  and  nerve  tissue,  etc.  The  true  solution  can  be  found  only 
in  a  hypererchetic  development  of  an  ovum,  a  cell  which  has  in 
it  the  power  of  formative  origin  for  all  these  structures.  The 
process  of  growth  of  the  ovum  after  impregnation  can  be  fol- 
lowed only  after  the  assumption,  either  expressed  or  uncon- 
sciously accepted,  of  such  a  hypothesis  as  is  contained  in  Mr. 
Darwin's  "Pangenesis."  The  germ  contributed  by  the  male 
contains,  we  knew  only  too  well  from  pathological  experience, 
gemmules  having  certain  powers  and  functions;  and  we  may 
therefore  assume,  as  indeed  we  also  know,  that  the  female  germ 
contains  also  such  gemmules.  It  may  be  that  the  ovum  has  in 
it  the  origin-buds  of  certain  tissues,  and  that,  under  exceptional 
hypererchetic  action,  they  may  go  on  to  the  rudimental  forma- 
tion of  these  tissues  without  a  fusion  with  the  male  germ.  More 
careful  and  accurate  description  of  what  is  found  in  dermoid 
cysts  may  help  to  solve  this  riddle;  still  better,  perhaps,  a  care- 
ful consideration  of  what  tissues  are  not  found  in  them. 

This  doctrine  of  hypererchesis  is  supported  by  many  facts 
which  have  been  observed  in  cases  where  the  changes  in  the 
13 


178  DISEASES   OF   THE   OVARIES. 

ovum  can  be  watched  outside  the  body  of  the  parent.  Thus  Bis- 
choff  and  Leuckhart  have  both  described  partial  development  of 
ovules  which  liave  been  placed  beyond  the  possibility  of  impreg- 
nation. Dr.  Moquin-Tandon  has,  more  recently  (1875),  described 
analogous  facts  before  the  Academie  des  Sciences,  among 
which  he  gives  details  of  the  process  of  segmentation  in  the  ova 
of  a  frog  which  had  been  kept  in  confinement  for  four  months. 

There  were  first  noticed  two  large  vertical  fissures  in  the 
ovule,  followed  soon  by  similar  horizontal  segmentation,  and 
this  process  of  division  proceeded  further,  but  in  a  less  regular 
manner  than  usual,  the  yolk  spheres  multiplying  irregularly, 
and  becoming  of  unequal  size,  and  it  was  more  rapid  than  in 
fecundated  eggs  which  were  allowed  to  develop  at  the  same 
temperature.  Only  a  small  number  of  the  ova  presented  this 
evidence  of  commencing  development,  for  the  majority  died 
without  any  sign  of  segmentation.  Sometimes  death  occurred 
after  the  division  into  two  or  four  segments,  sometimes  at  a 
more  advanced  period,  but  the  ovule  never  assumed  the  mul- 
berry appearance.  The  author  considers  that  this  incontestably 
proves  that  the  ova  of  vertebrata,  not  impregnated  by  sperma- 
tozoa, may  pass  through  the  earliest  stage  of  development  in 
certain  conditions,  the  exact  nature  of  which  is  at  present  un- 
known. It  seems  to  me  that  w§  may  take  this  process  to  be 
exactly  what  occurs  in  the  development  of  the  spore  of  the  fern 
into  the  prothallus,  and  the  tendency  which  these  unfertilized 
ovules  have  to  this  primitive  and  ineffectual  development  is 
derived  from  the  continuity  of  descent.  In  the  insecta  the  pro- 
cess is  carried  much  further,  for  Balbiani  exhibited  some  eggs 
of  the  silkworm  moth  to  the  Societe  de  Biologie  (1873),  which 
had  been  deposited  before  fecundation  could  have  been  effected. 
A  certain  number  of  these  eggs  remained  sterile,  but  others 
showed  signs  of  development,  though  in  no  instance  had  the 
larva  escaped  from  the  egg.  The  number  of  these  developing 
eggs  varied  extremely  according  to  the  species  of  moth  by  which 
they  were  deposited.  The  largest  number  was  met  with  in 
those  which  produce  several  generations  per  annum.  Among 
9,000  eggs  of  a  polyvoltine  race,  513  developed  spontaneously; 
while  of  50,000  of  an  annual  race,  29  only  were  fertile.  M.  Bal- 
biani thinks  that  this  enormous  difference  is  probably  due  to  the 
feeble  vitality  of  the  egg  in  the  annual  races,  a  suggestion  which 
cannot  be  considered  in  any  way  as  an  ex])lanation;  neither  can 
his  idea  be  entertained  tliat  tlie  partlienogenetic  development  is 
to  be  accepted  as  proving  the  hermaphroditism  of  the  egg,  for 
there  is  no  evidence  whatever  of  such  a  condition.  What  has 
been  observed  by  Balbiani  is  indeed  only  an  attempt  to  fulfil  the 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      179 

conditions  seen  in  the  aphides,  where  the  cell  multiplication  in 
the  pseudovaria  produce  a  new  individual  without  any  sexual 
congress.  Putting  these  facts  along  with  others  observed  by 
Agassiz  and  Burnette  in  fish,  by  Hensen  in  the  rabbit,  by  Bis- 
choff  in  the  sow,  and  more  especially  the  remarkable  observa- 
tion of  Oellacher,  that  segmentation  occurs  in  the  eggs  of  fowls 
kept  from  the  cold,  while  the  eggs  are  still  in  the  oviduct,  I  do 
not  think  that  there  is  any  difficulty  in  believing  that  the  hyper- 
erchetic  efforts  of  the  human  ovum  which  result  in  the  forma- 
tion of  those  so-called  dermoid  cysts,  are  parthenogenetic,  and 
have  originated  in  the  early  phases  of  our  ancestry.  In  the 
human  ovary  these  processes  are  carried  further  by  an  abun- 
dant blood-supply. 

Sir  James  Paget  has,  it  seems  to  me,  struck  the  key-note  of 
the  pathology  of  dermoid  cysts  when  he  wrote,  "  It  is,  perhaps, 
only  during  the  vigor  of  the  formative  forces  in  the  fetal  or 
earliest  extra-uterine  periods  of  life  that  cysts  thus  highly  organ- 
ized and  productive  are  ever  formed."  A  most  important  point 
in  the  pathology  hangs  on  this  sentence,  and  can  be  decided 
only  by  a  determination  of  the  age  at  which  such  tumors  are 
most  frequently  found.  It  is,  of  course,  evident  that  the  ages  at 
which  these  tumors  are  removed  by  the  operating  surgeon  can- 
not be  taken  into  account,  as  they  are  of  slow  growth,  and  have 
often  been  recognized  as  being  present  for  many  years  without 
perceptible  increase.  They  are  quite  unlike,  in  this  respect,  the 
ordinary  adenoid  tumors.  Their  contents  even  show  that  their 
existence  must  often  have  been  contemporaneous  with  the  life 
of  their  bearers  ;  for  we  find  large  balls  of  hair,  the  result  of  the 
epithelial  growth  and  shedding  of  a  nipple-like  process  not 
bigger  than  the  tip  of  one's  finger;  and  in  one  sac  over  three 
hundred  teeth  have  been  found,  resembling,  in  many  respects, 
milk-teeth;  so  that  we  may  reasonably  suppose  that  they  were 
the  repeated  products  of  a  limited  dentigenous  area.  In  one  of 
Mr.  Spencer  Wells's  cases,  the  preparation  of  which  is  in  the 
Hunterian  Museum,  a  piece  of  bone  was  found  resembling 
greatly  a  part  of  the  upper  maxilla  and  sphenoid  bones,  and  con- 
taining mature  molar  teeth.  In  fact,  inspection  of  the  specimen 
almost  carries  conviction  to  the  mind  that  the  bone  and  tooth- 
sacs  were  produced  at  an  early,  perhaps  intra-uterine,  period  of 
the  life  of  the  patient,  and  that  they  grew  and  matured  as  she 
did  till  the  tumor  was  removed,  at  the  age  of  thirty-nine. 

Dermoid  and  dentigenous  cysts  have  been  so  frequently 
found  in  children,  that  it  may  be  suspected  that  if  the  histories 
of  all  such  as  are  removed  by  operation  could  be  traced,  they 
would  be  found  to  be,  as  Paget  suggests,  either  congenital  or 


180  DISEASES   OF   THE   OVARIES. 

originating  very  early  in  life.  Indeed,  it  seems  to  me  to  be  im- 
possible that  it  can  be  otherwise  when  we  remember  how  soon 
after  birth  all  processes  of  development  must  cease,  and  those  of 
growth  alone  are  continued;  impossible  that  new  tissues,  so 
strange  and  displaced,  should  be  developed  after  the  formative 
powers  have  ceased  to  produce  new  tissues  in  normal  positions. 
The  more  we  know  of  pathology,  the  more  we  find  its  processes 
resemble  those  of  physiology;  and  it  seems  to  me  far  more 
simple  to  explain  the  occurrence  of  dermoid  cysts  in  the  ovary 
by  hypererchetic  action  of  an  ovum  at  the  time  of  life  when 
such  processes  are  in  vogue  in  the  economy,  than  at  some  other 
time  when  they  have  entirely  ceased  everywhere  else.  I  have 
already  shown  that  the  formation  and  destruction  of  ovarian 
cells  goes  on  from  the  earliest  to  the  latest  times  of  existence, 
the  degree  of  their  maturity  varying  with  the  periods  of  life. 
Fully  dilated  Graafian  follicles  are  often  seen  in  the  ovaries  of 
newly  born  children,  containing  ova  which  are  minute,  trans- 
parent, and  structureless  cells.  But  let  us  suppose  that,  during 
the  developmental  period  of  life,  some  stimulus  be  given  to  one 
Graafian  follicle  and  its  contained  ovum,  which  for  want  of 
better  knowledge  we  may  call  accidental,  and  that  this  should 
lead  to  the  premature  maturation  of  the  ovum,  so  that,  were  the 
rest  of  the  organism  ready  for  the  process,  it  might  be  carried 
into  the  uterus  and  there  be  impregnated.  Let  us  further  sup- 
pose that,  instead  of  being  destroyed  by  rupture  of  the  ovisac,  it 
should  remain  in  the  ovisac  and  share  alike  with  the  rest  of  the 
economy  in  developmental  activity,  there  could  be  only  one  re- 
sult, and  that  would  be  the  formation,  to  an  incomplete  degree, 
of  those  structures  which  it  would  evolve  in  perfection  under 
more  favorable  conditions. 

In  support  of  my  supposition,  I  may  draw  attention  to  a  de- 
scription further  on  of  a  dermoid  cyst  which  I  found  in  the  peri- 
toneum with  attachments  to  its  surface,  but  without  connection 
to  either  of  the  ovaries.  This  tumor  was  so  intimately  and  so 
extensively  adherent  to  the  peritoneum  that  I  had  to  leave  it, 
and  I  had  reason  to  believe  it  had  no  ovarian  connection.  Might 
not  such  be  developed  from  an  ovum  which  had  escaped  from 
the  ovaries  in  early  life,  and  become  attached  to  the  peritoneum, 
as  we  know  they  do  in  after  life,  and  there  have  carried  on  its 
attempt  at  parthenogenesis  ? 

The  logical  conclusion  of  this  view  is,  that  if  such  an  ovum 
could  get  into  the  uterus  after  its  escape,  it  would  develop  into 
a  perfect  instance  of  parthenogenesis — a  speculation,  of  course, 
but  no  wilder  than  some  of  the  facts  of  embryology  seemed  to  us 
before  we  understood  them.     It  is  in  fact  quite  analogous  to  the 


OVARIAN  TUMOKS,  CONDITIONS  WHICH  SIMULATE  TIIEM.      181 

production  of  the  aphis  by  a  virgin  and  sexless  larviparous 
mother. 

Whatever  may  be  the  value  of  the  suggestions  I  have  thrown 
out,  they  are  certainly  consistent  with  my  own  clinical  experi- 
ence; for  in  one  case  where  I  removed  a  dermoid  cyst  from  a 
young  woman,  there  were  many  reasons  for  believing  that  it 
had  existed  long  before  puberty.  The  oldest  patient  from  whom 
I  know  that  a  dermoid  cyst  has  been  removed  is  a  case  of  my  own, 
the  woman  being  in  her  forty-fifth  year.  The  tumor  weighed 
only  six  and  a  half  ounces,  and  was  full  of  hair,  which  had 
grown  and  been  shed  from  one  little  spot  of  skin  not  bigger  than 
the  tip  of  my  little  finger.  The  amount  of  hair  in  the  sac,  had 
it  grown  from  a  similarly  sized  area  of  scalp,  would  have  taken 
almost  a  lifetime  to  grow  and  be  shed.  In  Mr.  Wells's  oldest 
case  (38),  the  tumor  had  been  recognized  for  eighteen  years; 
and  in  a  case  (37)  not  operated  upon,  but  examined  after  death, 
the  tumor  had  been  known  to  be  in  existence  for  at  least  twelve 
years.  The  usual  age  for  dermoid  cysts  to  come  under  the 
notice  of  the  surgeon  is  from  seventeen  to  twenty  years,  and 
then"  it  is  generally  certain  that  they  have  been  long  in  exist- 
ence. After  puberty,  the  recurrent  congestion  of  the  whole  sex- 
ual apparatus  must  stimulate  into  growth  what  is  in  readiness 
for  it  after  having  been  developed  long  previously,  as  I  have 
suggested  in  my  hypothesis.  The  results  of  that  development 
may  remain  of  minute  or  even  microscopic  size,  until  the  stimu- 
lus of  the  menstrual  hypersemia  so  increases  them  as  to  make 
them  of  surgical  importance;  just  as  Hunter's  celebrated  experi- 
ment of  the  transplantation  of  the  spur  of  the  cock  into  his 
coinb  resulted  in  an  extraordinary  increase  in  length  and  size  of 
the  spur  by  the  altered  character  of  its  hsemic  nutrition.  Occa- 
sionally, however,  they  grow  to  a  large  size  before  puberty. 

At  a  meeting  of  the  Pathological  Society  of  London,  on  Tues- 
day, May  5,  1874,  Dr.  Dickinson  showed  an  ovarian  tumor  re- 
moved from  a  child,  aged  ten,  at  the  post-mortem  examination. 
About  twelve  months  previously  the  child  complained  of  pain  in 
the  right  side,  and  lower  part  of  the  abdomen,  and  then  a  small 
swelling  the  size  of  an  egg  was  noticed.  In  six  months'  time 
this  was  as  large  as  a  small  apple.  It  then  rapidly  increased. 
When  first  seen  the  umbilical  girth  was  twenty-five  inches,  and 
she  was  in  much  pain.  The  diagnosis  was  difficult,  and  it  Avas 
at  first  supposed  to  be  a  malignant  growth  of  the  kidney.  She 
was  removed  from  the  hospital,  and  on  her  return,  some  months 
after,  the  umbilical  girth  was  twenty-seven  and  one-half  inches. 
She  died  soon  after  of  peritonitis.  A  tumor  of  the  right  ovary 
was  found,  weighing  five  and  one-half  pounds.     It  contained 


182  DISEASES   OF   THE   OVARIES. 

hair,  bones,  etc.  All  the  other  organs  of  the  body  were  healthy. 
The  child  had  never  menstruated.  An  exploratory  incision 
■would  probably  have  saved  this  child's  life. 

Briefly,  then,  I  believe  dermoid  cysts  to  be  the  result  of  hy- 
phererchetic  development  of  an  ovum  in  fetal  or  infantile  life, 
growing  into  a  tumor  during  and  subsequently  to  puberty. 
They  are  always  invested  by  the  ordinary  peritoneal  covering  of 
the  ovary,  beneath  which  is  a  more  or  less  thick  layer  of  the 
nucleated  and  banded  fibrous  tissue,  which  forms  the  basis  of 
all  ovarian  cysts.  I  have  seen  this  layer  as  thin  as  tissue  paper, 
and  in  one  old-standing  dermoid  cyst  it  was  more  than  an  inch 
thick,  and  occupied  by  large  plates  of  calcification.  In  it  are  to 
be  found  the  same  almond-shaped  nuclei  which  characterize  the 
stroma  of  the  ovary,  only  they  are  sparsely  distributed,  as  I  have 
already  said  they  always  are  in  old  tumors.  Within  this  layer 
the  peculiar  structures  met  with  in  dermoid  cysts  occur,  an  ar- 
rangement strongly  indicative  of  the  method  of  origin  which  I 
have  suggested  for  them.  I  do  not  know  of  any  tissue  in  the 
body  which  may  not  find  its  representative  in  them,  for  Beneke 
has  even  found  brain-substance.  Usually,  however,  they  have 
an  epithelial  character,  and  in  some  instances  show  great  ad- 
vance both  in  development  and  growth.  When  skin  or  mucous 
membrane  is  present,  all  the  details  of  their  structure  may  be 
made  out;  and  as  there  is  no  vasomotor  check  on  the  vascular 
supply,  the  materials  which  they  secrete  normally  are  often 
found  in  vast  quantities,  as,  for  instance,  hundreds  of  teeth,  and 
pounds  of  sebaceous  matter. 

Another  kind  of  tumor,  undoubtedly  of  ovarian  origin,  though 
without  the  appearance  of  any  relation  to  the  ovary  save  that  of 
contiguity,  has  several  times  come  under  my  observation,  and 
as  I  have  met  with  no  description  of  a  precisely  similar  case, 
I  am  induced  to  place  on  record  a  full  description  of  it.  The  first 
case  was  in  a  patient,  thirty-seven  years  of  age,  who  was  placed 
under  my  care  by  Dr.  Blackwood,  of  Wednesbury,  who  had  at- 
tended her  in  three  confinements,  the  first  of  which  was  natural, 
the  second  had  to  be  completed  by  the  use  of  forceps,  and  in  the 
third  version  had  to  be  performed  on  account  of  obstruction. 
The  last  labor  occurred  in  1860,  and  after  that  till  the  time  I  saw 
her,  April,  1873,  menstruation  occurred  normally.  During  that 
time  a  protrusion  from  the  vulva  gradually  formed,  and  when 
first  seen  by  Dr.  Blackwood  it  had  reached  an  enormous  size, 
and  included  the  uterus,  bladder,  and  rectum,  and  it  had  become 
perfectly  irreducible.  Dr.  Blackwood  also  discovered  a  large 
abdominal  tumor,  which  seemed  to  be  the  cause  of  the  protru- 
sion.    I  found  that  this  tumor  extended  to  about  four  inches 


ovaria:n"  tumors,  coxditioxs  which  simulate  them.    183 

above  the  umbilicus,  that  it  filled  the  pelvis,  and  the  character 
of  the  fluctuation  made  it  apparent  that  it  was  a  unilocular  cyst. 
It  was  very  much  fixed  in  the  pelvis,  so  that  I  gave  the  opinion 
that  it  was  adherent,  and  that  probably  much  difficulty  would 
be  encountered  in  its  removal,  but  as  its  growth  had  been  rapid 
I  advised  an  exploratory  incision.  This  I  made  in  the  usual 
way  on  April  27th,  but  could  find  no  line  of  demarcation  between 
the  peritoneum  and  the  cyst-wall.  The  latter  was  very  much 
thickened,  and  on  being  cut  through  it  was  seen  to  contain  a 
large  number  of  hairs,  not  growing  into  the  cyst,  as  is  usually 
the  case,  but  growing  merely  in  the  wall,  for  not  a  hair  was  to 
be  found  free  on  the  inner  surface  of  the  cyst.  The  contents 
consisted  of  clear  serous  fluid,  in  which  floated  long  processes  of 
translucent  membrane,  exactly  resembling  the  omentum  of  a 
fcetus;  and  there  was  also  one  long  finger-like  process  of  pure 
fat,  encapsuled  in  serous  membrane.  The  sac  was  emptied  of 
everything,  and  attempts  were  made  on  every  side  to  discover  a 
division  between  it  and  the  peritoneal  cavity.  Above,  I  dis- 
sected till  I  found  that  its  union  with  the  intestines  was  so  inti- 
mate as  to  render  its  removal  impossible.  On  each  side  it 
seemed  to  be  entirely  continuous  with  the  abdominal  walls  as 
far  as  the  brim  of  the  pelvis.  Below  it,  the  uterus  and  ovaries 
were  felt  to  be  quite  free,  so  that  it  was  made  certain  that  the 
tumor  was  not  ovarian,  and  behind  it  the  intestines  could  be  felt 
in  a  cavity  which  probably  extended  down  to  Douglas's  pouch. 
When  these  details  had  been  made  out,  it  became  quite  evident 
that  the  proper  treatment  for  this  anomalous  case  was  to  close 
the  wound,  save  at  its  lower  angle,  where  a  drainage-tube  was 
placed;  but  before  I  did  so,  I  removed  a  fragment  of  the  wall  of 
the  cyst  in  which  I  had  noticed  the  hairs.  I  need  not  give  a  de- 
tailed account  of  her  progress  toward  recovery,  more  than  to  say 
that  the  cyst  suppurated  freely,  and  that  the  suppuration  slowly 
diminished,  so  that  in  July  I  removed  the  drainage-tube.  In 
October  there  still  remained  a  slight  discharge  from  the  site  of 
the  drainage-tube,  all  tendency  to  protrusion  from  the  vulva  had 
ceased,  and  it  could  be  felt  that  the  roof  of  the  pelvis  was  some- 
what fixed  and  the  uterus  retro  verted.  The  wound  also  was 
slightly  drawn  inward,  but  there  was  no  other  trace  of  the  tumor. 
The  patient  now  (1880)  enjoys  robust  health,  and  still  menstru- 
ates regularly. 

Examination  of  the  fragment  of  the  cyst-wall  which  I  re- 
moved showed  that  hairs  were  growing  in  it,  or  at  least  existed 
in  it,  in  large  numbers,  and  that  they  all  lay  in  a  direction  par- 
allel to  the  cyst-wall.  There  were  also  traces  of  rudimentary 
skin  structures,  as  papillae,  fat  loculi,  and  something  like  glands, 


184  DISEASES   OF   THE   OVARIES. 

quite  sufficient  to  place  this  remarkable  tumor  within  the  cate- 
gory of  dermoid  cysts;  and  in  this  direction  also  the  serous  mem- 
brane found  within  it  pointed.  What,  then,  was  its  origin  ?  In 
answer  to  this,  only  two  suppositions  can  be  entertained,  the 
first  and  least  likely  of  which  is  that  it  was  an  inclusion  cyst, 
similar  to  that  already  referred  to  as  situated  at  the  Torcular 
Herophyli.  The  other,  and  I  think  that  which  must  be  accepted, 
is  that  it  had  grown  out  of  a  wandering  ovum,  which,  after  its 
escape  from  its  Graafian  follicle,  had  failed  to  be  extruded  in  the 
ordinary  way,  had  not  died,  but  had  gone  on  to  a  hypererchetic 
development. 

We  know  that  ova  are  sometimes  matured  in  infantile,  even 
in  embryonic  life,  and  also  that  they  sometimes  undergo  this 
hypererchetic  development  in  the  ovary.  In  adult  life,  we  also 
know  that  all  the  ova  which  escape  from  the  follicles  do  not 
reach  the  uterus,  and  it  is  more  than  probable  that  a  large  num- 
ber of  them  escape  into  the  peritoneal  cavity,  and  there  wander 
till  they  die.  As  the  ovum  when  impregnated  fixes  itself  at  once 
to  the  surface  with  which  it  is  at  the  time  in  contact,  and  there 
develops,  so  it  is  not  impossible  that  one  of  these  hypererchetic- 
ally  inclined  ova,  having  escaped  into  the  peritoneal  cavity, 
there  becomes  adherent,  and  grows  into  such  a  dermoid  cyst  as  T 
found  in  Dr.  Blackwood's  case.  All  the  circumstances  necessar}' 
for  this  coincidence  being  rare,  of  necessity  its  results  will  be 
rare;  but  as  our  surgical  experience  of  such  matters  is  just,  as  it 
were,  beginning,  such  a  case  as  the  one  I  have  narrated  may  not 
be  without  a  parallel.  Certain  it  is  that  I  have  met  with  no  de- 
scription of  an  exactly  similar  instance,  though  the  develop- 
ment of  wandering  ova  into  cysts  is  a  possibility  recognized  by 
several  authors,  especially  by  Boinet.  Dr.  Lloyd  Roberts,  of 
Manchester,  has  described  a  similar  cystic  tumor  which  he  re- 
moved successfully,  which  had  no  connection  with  the  uterus  or 
ovaries,  and  which  he  regarded  as  a  non-fecundated  ovule  which 
had  dropped  into  the  peritoneal  cavity,  and  there  become  enor- 
mously developed. 

I  have  met  with  quite  a  series  of  cases  to  which  I  think  no 
other  explanation  can  be  given  than  such  as  I  have  advanced 
for  the  case  described  above.  In  none  of  them  were  there  any- 
thing like  dermoid  structures,  though  in  other  respects  they 
closely  coincided  witli  its  appearances,  and  tliey  had  features 
perfectly  in  common,  more  particularly  in  tlie  matter  of  their 
relations  to  the  pelvic  and  abdominal  organs.  The  series  in- 
cludes six  cases,  of  which  I  need  only  describe  one,  as  there  wag 
nothing  different  in  any  of  them,  either  in  appearance,  treat- 
ment, or  result.     They  were  all  young  women,  from  fifteen  to 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      185 

twenty-six  years  of  age,  and  they  had  all  the  physical  characters 
of  parovarian  cysts.  When  I  came  to  operate,  however,  I  found 
that  between  the  cyst  and  the  peritoneum  there  was  an  absolute 
adhesion,  and  when  I  opened  the  cyst  I  evacuated  a  large  quan- 
tity of  perfectly  limpid  fluid.  The  cysts  were  lined  with  epithe- 
lium, and  had  a  perfectly  smooth,  glistening  surface.  They 
were  intimately  adherent  to  the  whole  of  the  pelvic  surface  and 
also  to  the  posterior  abdominal  wall.  For  some  two  or  three 
inches  above  the  pelvic  brim  this  adhesion  extended  in  a  slop- 
ing line  forward,  upward,  and  outward  to  a  level  an  inch  or  two 
above  the  umbilicus.  From  this  line  of  attachment  the  cysts 
seemed  to  be  free,  and  when  emptied  the  intestines  pushed  down 
the  upper  wall  into  the  cyst  cavity  like  a  huge  pouch.  In  every 
one  of  the  cases  the  uterus  and  ovaries  could  be  felt,  in  their 
normal  situation,  through  the  cyst-wall,  and,  as  far  as  could  be 
determined,  perfectly  healthy,  and  independent  of  the  cyst. 

They  were  therefore  not  ovarian  tumors,  and  they  certainly 
were  not  of  parovarian  origin  ;  and  the  uniformity  of  their  rela- 
tions makes  it,  I  think,  certain  that  they  form  a  specific  class  of 
pathological  cysts.  In  the  first  case  I  met  with,  which  was  sent 
to  me  by  Dr.  Eshelby,  of  Stonehouse,  some  years  ago,  I  tried  very 
hard  to  remove  the  cyst,  but  failing  to  do  so,  I  inserted  a  large 
drainage- tube,  keeping  it  in  for  some  weeks,  and  in  this  way  I 
cured  the  cyst,  and  the  girl  now  remains  perfectly  "well. 

The  same  history  is  to  be  given  of  the  other  five  cases,  and  in 
the  last  four  I  have  been  able  to  recognize  at  once  the  nature  of 
the  case,  and  have  therefore  made  no  attempt  to  enucleate  the 
tumor,  but  have  been  content  with  draining  it  in  the  method  de- 
scribed. 

My  impression  about  these  cases  is,  as  I  have  said,  that  they 
are  cysts. formed  by  a  dropsical  distention  of  an  ovule  which  had 
not  been  impregnated  and  which  dropped  into  the  peritoneal 
cavity  and  had  there  become  attached  and  developed. 

There  is  a  class  of  tumors  which  closely  simulate  cystic  tu- 
mors of  the  ovary  which  I  have  seen  occasionally  referred  to  in 
published  accounts  of  operations  as  extra-peritoneal  cysts,  and 
in  one  case,  at  least,  the  description  is  such  as  makes  it  clear  that 
the  writer  regards  the  tumor  as  having  been  a  true  ovarian  cys- 
toma developed  outside  the  peritoneal  cavity.  It  is,  of  course, 
absolutely  impossible  to  accept  any  such  explanation  for  these 
tumors,  for  one  cannot  see  how  a  tumor  of  the  ovary,  or  a  tu- 
mor developed  from  a  wandering  ovum,  could  by  any  possibility 
be  developed  on  the  outer  side  of  the  membrane  of  the  perito- 
neum. In  my  own  practice  I  have  only  seen  two  cases  of  extra- 
peritoneal cysts,   and  in  both  of  them  the   operation  unfortu- 


186  DISEASES    OF    THE    OVARIES. 

nately  proved  fatal.  A^  no  post-mortem  examination  could  be 
obtained  in  either  instance,  it  remains  quite  uncertain  Avhat  the 
exact  nature  of  the  tumor  really  was,  though  I  think  I  have  a 
satisfactory  explanation  to  give  of  them. 

The  first  case  that  I  met  with  was  in  a  lady,  aged  fifty-six, 
under  the  care  of  Dr.  Lamb,  of  Albrighton,  who  for  twelve 
months  before  had  complained  of  abdominal  pain  and  tender- 
ness, and  in  October,  1880,  began  to  suffer  from  somewhat  seri- 
ous symptoms,  more  particularly  frequent  vomiting  and  disin- 
clination to  take  solid  food.  Some  swelling  in  the  lower  part  of 
the  abdomen  was  noticed  about  the  same  time,  this  being  then 
regarded  as  ascitic.  The  symptoms  slowly  increased  in  severity 
until  February  11,  1881,  when  a  consultation  was  held  between 
Drs.  Lamb,  Heslop,  and  Saundby.  As  a  result  of  this  consulta- 
tion she  was  tapped  and  ten  pints  of  fluid  were  removed, 
though  this  Avas  by  no  means  the  quantity  of  fluid  in  the  cav- 
ity, because  large  masses  of  flocculi  obstructed  the  tube  of  the 
trocar,  and  prevented  the  complete  emptying  of  the  cyst.  Some 
of  this  fluid  was  submitted  to  me  for  an  opinion,  and  from 
the  facts  that  it  was  brown  and  thick  and  gave  an  abundant 
flaky,  yellow  deposit  which  consisted  chiefly  of  pus,  I  unhesita- 
tingly gave  the  opinion  that  it  was  not  ascitic,  but  a  fluid  that 
must  have  been  contained  in  some  cyst  cavity,  probably  a  cyst 
of  the  parovarium.  I  saw  her  on  February  i;3th,  when  we  found 
that  the  abdomen  was  quite  as  much  distended  as  before  the 
tapping.  I  therefore  proposed  an  exploratory  incision  for  the 
removal  of  the  tumor,  if  it  were  possible  to  remove  it,  although 
the  extremely  exhausted  condition  of  the  patient  gave  no  very 
great  prospect  of  success.  It  Avas  perfectly  clear,  however,  that 
if  left  alone  nothing  but  death  could  be  the  result,  and  therefore 
an  operation  was  accepted  by  her  attendants  and  relatives. 

I  opened  the  abdomen  at  the  usual  site,  and  after  cutting 
through  all  the  layers  except  the  peritoneum  I  came  upon  the 
cyst  wall.  I  opened  the  cyst  and  removed  about  thirty  pints  of 
fluid  exactly  the  same  as  that  which  had  been  removed  at  the 
tapping,  and  mixed  up  with  it  I  found  large  masses  of  the  fibri- 
nous deposit,  which  accounted  for  the  failure  of  the  tapping  to 
remove  the  whole  of  the  fluid.  I  then  proceeded  to  remove  the 
enormous  cyst,  wliich  was  uniformly  attached  to  the  parietal 
wall  on  its  outer  aspect  and  to  the  outer  surface  of  the  thickened 
peritoneum  on  its  posterior  aspect.  The  cyst  did  not  dip  into  the 
pelvis  at  all,  and  the  anterior  parietal  peritoneum  did  not  reach 
the  wall  lower  than  the  ensiform  cartilage.  The  intestines  and 
the  pelvic  organs  could  be  felt  through  the  anterior  peritoneal 
fold,  non-adherent  and,  as  far  as  could  be  determined,  perfectly 


OVxVEIA]^  TUMORS,  CONDITIONS  AVIIICU  SIMULATE  TIIEM.      187 

healthy.  The  cyst  lay,  therefore,  entirely  between  the  trans- 
versalis  fascia  on  the  outer  side  and  the  parietal  peritoneum  on 
the  inner,  the  peritoneal  cavity  having  been  nowhere  opened 
during  the  protracted  and  severe  operation.  The  cyst  was  re- 
moved in  its  entirety,  and  its  inner  surface  consisted  of  broken- 
down  mucoid  epithelium,  infiltrated  everywhere  with  pus,  lying 
upon  the  basement-membrane,  which  consisted  almost  entirely 
of  muscular  fibre. 

The  conclusion  concerning  the  nature  of  this  cyst  at  which  I 
have  arrived  is  that  it  was  developed  from  the  urachus,  a  part 
of  which  had  been  occluded  at  both  ends,  but  during  the  de- 
velopmental changes  of  embryonic  and  infantile  existence  had 
not  become  obliterated.  I  entirely  fail  to  see  any  other  possible 
origin  for  it,  and  if  my  explanation  be  correct  it  is  very  marvel- 
lous that  this  structure  should  have  remained  quiescent  for  fifty- 
six  years  and  then  should  suddenly  undergo  an  inflammatory 
change  which  developed  it  into  this  enormous  cyst.  The  patient 
went  on  very  well  for  about  three  days  and  then  rapidly  sank 
from  exhaustion.  E"o  post-mortem  examination  was  allowed, 
and  therefore  I  can  shed  no  further  light  upon  it,  and  as  far  as  I 
know  the  observation  is  unique,  although  it  is  perfectly  well 
known,  as  I  myself  have  repeatedly  had  occasion  to  observe,  that 
small  cysts  of  the  urachus  are  opened  in  abdominal  section.  I 
do  not  know  that  any  such  cyst  has  previously  been  met  with 
sufficiently  large  to  be  of  pathological  importance. 

The  second  case  of  extra-peritoneal  cyst  was  sent  to  me  by 
Dr.  Craig,  of  Stoke-upon-Trent.  Here  again  the  patient  was 
almost  hopelessly  beyond  the  reach  of  surgical  interference  be- 
fore I  saw  her.  The  tumor  had  been  recognized  by  Dr.  Craig  in 
1878,  and  then  he  had  recommended  her  to  put  herself  under  my 
care  for  its  removal.  She,  however,  declined  to  do  so  until  the 
middle  of  last  May,  and  when  she  arrived  in  Birmingham  she 
waspractically  moribund.  I  happened  to  be  from  home  when 
she  reached  my  house,  and  my  servants  were  under  the  impres- 
sion she  would  never  leave  the  house  alive.  She  was  placed  in 
lodgings  close  by,  and  I  operated  upon  her  immediately  on  my  re- 
turn, three  days  afterward.  The  cyst  I  found  gangrenous  and 
full  of  pus,  with  a  large  mass  of  broken-down  lymph.  It  was 
situated  entirely  outside  the  peritoneum,  which  Avas  never 
opened  at  all,  and  it  dipped  down  into  the  pelvis  on  the  right  side 
only.  As  far  as  I  could  make  out,  its  structurQ  was  very  much 
like  the  other,  save  that  it  extended  almost  entirely  on  the  right 
side,  the  peritoneum  seeming  to  be  pushed  altogether  toward 
the  left.  Its  characters  were  very  m.uch  like  those  of  Dr.  Lamb's 
case  just  described. 


183  DISEASES    OF   THE    OVARIES. 

She  rallied  from,  the  operation  very  well,  and  for  eight  days 
seemed  likely  to  recover,  but  as  soon  as  the  stitches  were  re- 
moved from  the  wound  it  reopened  and  continued  to  discharge 
a  large  quantity  of  unhealthy  brown  purulent  fluid  until  her 
death,  seventeen  days  after  the  operation.  Here  again,  unfor- 
tunately, no  post-mortem  examination  was  obtained,  and  there- 
fore I  can  say  nothing  with  absolute  certainty  as  to  the  origin  of 
the  tumor,  but  my  belief  is  that  this  also  was  a  cyst  of  the 
urachus. 

In  both  of  these  cases  I  inserted  drainage-tubes  into  the  cavity 
left  by  the  cysts,  and  I  am  under  the  impression  these  tubes  had 
something  to  do  with  the  fatal  results,  though  this  may  not  be 
the  case.  The  explanation  of  the  deaths  is  of  course  first  of  all 
to  be  found  in  the  advanced  condition  of  exhaustion  in  which 
both  patients  were  at  the  time  of  operation,  and  I  think  it  very 
likely  that  a  fortunate  result  would  have  been  obtained  in  both 
of  them  if  the  operations  had  been  performed  earlier  in  the  his- 
tories of  the  cases.  Perhaps  the  immediate  cause  of  death  was 
the  destruction  of  the  vitality  of  the  peritoneum,  which  was  as- 
sociated with  the  inner  wall  of  the  cyst.  In  both  cases  the  ex- 
tent of  peritoneum  denuded  from  the  cyst-tissue,  to  which  it 
doubtless  owed  its  blood-supply,  was  very  great,  and  if  this  im- 
portant structure  died  from  loss  of  its  blood-supply,  it  would  of 
course  be  quite  sufficient  to  account  for  the  deaths  of  the 
patients.  I  think  if  I  should  ever  have  similar  cases  I  should 
feel  inclined  to  remove  a  large  portion  of  this  denuded  perito- 
neum and  trust  to  a  careful  arrangement  by  sutures  of  the  por- 
tions left  rather  than  run  the  risk  of  what  I  think  may  have 
been  the  cause  of  death,  for  I  often  find  I  have  to  remove  in 
cases  of  adherent  cyst  a  very  large  piece  of  parietal  peritoneum, 
and  this  is  done  without  interfering  in  any  way  with  the  recovery 
of  the  patient. 

These  cases  illustrate  very  well  the  unexpected  and  great  dif- 
ficulties which  arise  in  the  practice  of  abdominal  surgery,  and 
how  much  we  have  yet  to  learn  in  this  important  branch  of  our 
art.  They  also  illustrate  the  abundant  causes  we  have  for  re- 
gretting that  abdominal  tumors  are  often  allowed  to  go  so  long 
as  to  remove  any  reasonable  prospect  of  success  in  dealing  with 
them. 

Before  dealing  with  the  very  numerous  conditions  which  sim- 
ulate ovarian  iRimors  it  will  be  convenient  if  I  now  discuss  the 
signs  and  symptoms  by  which  an  ovarian  tumor  may  be  recog- 
nized; and  I  may  here  say  at  once  that  the  conditions  which 
mimic  these  tumors  are  so  numerous,  and  tliere  are  so  few 
facts  in  connection  with  them  upon  which  implicit  reliance  can 


OVAKIA^S"  TUMOllS,   COXDITIOXS  WHICH  SIMULATE  TIIE^I.      189 

be  placed,  that  safety  is  to  be  found  only  in  the  process  of 
reasoning  by  exclusion;  that  is,  for  a  proper  diagnosis  in  the 
case  of  an  ovarian  tumor  it  will  be  found  the  best  plan,  first  of 
all,  to  make  a  mental  list  of  all  the  conditions  that  it  may  be, 
and  exclude  them  one  after  another  until  no  alternative  is  left. 
Any  one  who  habitually  follows  a  converse  plan  will  sooner  or 
later  be  led  into  some  fatal  blunder.  Our  anxiety  should  always 
be,  not  to  prove  that  a  given  tumor  is  ovarian,  but  to  show  that 
it  cannot  by  any  possibility  be  anything  else. 

It  may  be  said  with  perfect  certainty  that  from  the  history 
alone  no  ovarian  tumor  could  be  diagnosed,  so  various  are  the 
stories  told  by  the  patients  about  their  cases.  Thus  one  patient 
will  present  herself  totally  unaware  of  the  fact  tliat  there  is  any 
tumor,  her  only  sensation  being  one  of  discomfort  from  the  swell- 
ing, while  another  may  have  known  for  many  years  of  the  pres- 
ence of  a  small  lump  which  had  long  remained  quiescent,  and 
had  taken  to  enlarging  only  for  a  few  weeks  or  months.  The 
rate  of  increase  gives  no  guide,  either  in  unilocular  or  in  multi- 
locular  tumors  ;  for  I  have  removed  multilocular  tumors  which 
had  been  in  progress  for  a  great  many  years,  and  I  have  re- 
moved one  of  great  size  from  a  patient  aged  sixty-six,  which 
had  grown  in  four  months.  I  have  removed,  on  the  other  hand, 
a  large  unilocular  parovarian  tumor  which  had  been  in  existence 
for  more  than  ten  years,  and  the  structure  of  which  showed  that 
it  always  had  been  unilocular  ;  and  I  have  removed  two  unilocu- 
lar tumors,  one  of  which  grew  so  as  to  completely  distend  the 
abdomen  in  seven  weeks,  and  another,  almost  as  large,  which 
had  not  been  noticed  for  more  than  five  weeks. 

The  details  given  by  the  patients  as  to  the  region  in  which 
the  tumors  were  iirst  observed  are  often  very  misleading,  and  no 
dependence  whatever  can  be  placed  on  some.  One  patient,  in 
whom  there  existed  an  undoubted  fibroid  tumor  of  the  uterus, 
asserted  that  it  originally  grew  somewhere  in  the  neighborhood 
of  the  spleen,  and  gradually  descended  to  its  present  uterine 
situation.  Tumors  of  one  ovary  are  often  stated  by  their  bearers 
to  have  originated  on  the  side  opposite  to  that  from  which  they 
are  found  to  grow.  One  condition  which  on  rare  occasions  comes 
under  our  notice,  hydatids  of  the  peritoneum,  beginning  as  it 
does  generally  by  rupture  of  an  acephalocyst  of  the  liver,  pre- 
sents usually  a  history  of  origin  at  the  upper  part  of  the  abdo- 
men ;  so  that,  when  such  a  story  is  given  with  subsequent  gen- 
eral enlargement  of  the  abdomen,  caution  is  necessary  before 
excluding  liydatids  from  the  possibilities.  A  tumor  which  began 
centrally  and  remains  so  is  of  course  likely  to  be  uterine  ;  but 
this  is  far  from  being  constantly  the  rule.     I  have  heard  a  pa- 


190  DISEASES    OF   THE   OVARIES. 

tient  state  that  an  ovarian  tumor  of  considerable  size  had  ap- 
peared suddenly  ;  and  this  might  ha^^e  really  happened,  for  its 
escape  from  the  pelvis  might  have  been  sudden,  I  have  often 
pushed  an  ovarian  tumor  out  of  the  pelvis  that  had  been  im- 
Ijacted  there,  and  the  same  thing  may  be  experienced  with 
uterine  myomata. 

The  menstrual  histories  given  by  patients  with  ovarian  tu- 
mors have  been  so  various,  in  my  experience;  as  to  lead  me  al- 
most entirely  to  disregard  them  in  the  diagnosis.  Dubois  asserted 
that  he  had  not  known  an  ovarian  cystic  tumor  accompanied  by 
hemorrhage,  but  this  has  been  repeatedly  noticed  in  my  prac- 
tice ;  and  the  explanation  of  the  apparent  discrepancy  is  that, 
when  the  great  obstetrician  wrote,  the  diagnosis  of  pelvic  tu- 
mors had  not  arrived  at  its  present  state.  In  some  instances, 
two  of  which  I  have  already  detailed,  ovarian  tumors  gave  rise 
to  uncontrollable  menorrhagia,  and  I  have  pointed  out  that  there 
seems  to  be  a  close  association  with  small  cystic  ovaries  and  this 
serious  symptom. 

I  have  frequently  known  complete  arrest  of  menstruation  to 
be  associated  with  rapidly  growing  tumors  both  of  the  ovary  and 
parovarium.  Such  a  fact  in  the  history  of  any  case  ought  to 
make  us  especially  careful  to  eliminate  pregnancy,  more  espe- 
cially the  condition  of  hydramnios,  which  I  have  known  to  be 
treated  fatally  on  two  occasions  by  tapping,  once  as  an  ovarian 
tumor  and  once  as  ascites.  The  uterus,  in  the  early  months  of 
normal  pregnancy,  is  not  unfrequently  displaced  to  one  or  other 
side,  and  has  been  often  mistaken  for  an  ovarian  cyst ;  in  one 
case,  by  myself,  for  an  abscess  in  the  broad  ligament.  In  this 
latter  case,  I  was  led  astray  by  the  general  symptoms  of  hectic 
from  which  the  patient  suffered.  It  was  to  me  a  lesson  to  trust 
to  no  one  symptom,  nor  to  any  group  of  symptoms,  in  a  pelvic 
diagnosis  ;  fortunately  the  patient  recovered  completely  after  a 
miscarriage. 

A  large  number  of  cases  of  ovarian  tumor  are  met  with  near 
the  climacteric  period  of  life,  and  it  is  not  unusual  for  their  ap- 
pearance to  be  ushered  in  by  a  premature  arrest  of  menstruation : 
so  that  during  the  first  few  months  of  the  growth  of  the  tumor 
the  patient  takes  it  for  granted  that  she  is  pregnant.  It  is  some- 
what curious  tliat  I  have  had  at  the  same  time  under  my  care 
two  cases  upon  whom  I  performed  ovariotom3^  in  both  of  whom 
pregnancy  was  believed  to  exist  for  many  months  until  the  lapse 
of  time  made  an  investigation  advisable.  Arrest  of  menstrua- 
tion occurred  in  ])oth  before  tlie  tumor  was  observed,  so  that  the 
abdominal  enlargement  was  of  course  taken  for  pregnancy.  In 
one  case  the  abdominal  parietes  were  so  dropsical  that  it  was  a 


OVAKTAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      191 

matter  of  great  difficulty  to  be  certain  that  there  was  not  preg- 
nancy as  well  as  an  ovarian  tumor,  the  difficulty  being  overcome 
by  the  use  of  the  sound  after  some  hesitation. 

For  the  diagnosis  of  ovarian  tumors,  either  subjective  or  dif- 
ferential, there  are  varieties  of  symptoms,  almost  numberless, 
the  great  majority  being  of  little  or  no  consequence  for  accu- 
racy, and  none  of  them  alone  being  trustworthy.  The  symp- 
toms vary  in  their  character  and  intensity  very  much  according 
to  the  size  of  the  tumor,  though  this  is  far  from  being  the  rule. 
■Thus  the  largest  ovarian  tumor  which  I  have  removed,  some- 
where over  one  hundred  pounds  in  weight,  gave  rise  to  no  other 
symptoms  than  the  inability  of  the  patient  to  get  about  from  its 
immense  weight ;  while  the  smallest,  only  six  and  a  half  ounces, 
was  the  source  of  agonizing  pain  and  a  great  variety  of  reflex 
symptoms,  including  aphonia  ;  and  it  had  completely  disabled 
the  patient  for  some  years.  In  the  early  growth  of  a  simple  cyst, 
symptoms  of  any  kind  are  seldom  met  with  until  the  tumor  is 
sufficiently  large  to  be  impacted  in  the  pelvis.  The  growth  of 
dermoid  cysts,  on  the  contrary,  is  often  accompanied  by  pain  of 
a  most  intense  kind,  for  which  no  explanation  can  be  advanced. 

In  one  case,  already  referred  to,  I  had  to  remove  a  very  small 
dermoid  cyst  on  account  of  the  agonizing  pain  in  it.  Though 
this  has  been  relieved  completely,  a  variety  of  nervous  symp- 
toms have  supervened,  very  mysterious  in  their  nature,  for 
which  no  remedy  has  been  found,  and  which,  among  other  re- 
sults, have  induced  a  contraction  in  the  hamstring  muscles,  and 
an  absolute  rigidity  of  the  knees,  so  that  the  patient  has  never 
been  able  to  walk  since  the  operation,  now  nearly  ten  years. 

As  a  rule,  pain  is  not  met  with  until  cystic  tumors  are  large 
enough,  if  out  of  the  pelvis,  to  press  on  important  viscera;  or 
unless  the  surface  of  the  tumor  undergoes  inflammatory  change. 
In  the  latter  case,  pain  and  increase  of  pulse  and  temperature  are 
the  indications,  though  it  is  surprising  to  what  an  extent  a  tumor 
may  be  found  to  be  adherent,  and  yet,  throughout  its  history,  no 
indications  of  inflammatory  attacks  have  been  given.  Until  the 
tumor  is  sufficiently  large  to  interfere  with  nutrition,  and  if  it 
be  not  of  a  cancerous  character,  there  are  rarely  any  symptoms 
of  constitutional  disturbance;  though  sometimes  I  have  seen  a 
small  tumor  very  loose  in  the  cavity  of  the  abdomen  give  rise  to 
great  pain  and  discomfort.  Such  tumors  also  occasionally  give 
rise  to  symptoms  of  intestinal  obstruction,  as  was  the  case  in  the 
instance  of  a  large  uterine  myoma  which  I  successfully  removed 
by  abdominal  section. 

During  the  growth  of  an  ovarian  tiimor,  the  appetite  is  usually 
not  interfered  with  until  the  case  is  far  advanced;  nor  is  sleep. 


192  DISEASES   OF   THE   OVARIES. 

though  it  is  often  found  that  the  patient  can  lie  only  on  one  side; 
nor  do  we  find  that  either  the  temperature  or  the  pulse  is  affected 
to  any  appreciable  extent.  Hysteria  is  sometimes  found  in  con- 
nection with  ovarian  tumors,  and  dependent  directly  upon  them. 
In  one  of  my  cases  this  was  markedly  the  fact,  for  the  hysteria 
disappeared  entirely  after  recovery  from  ovariotomy.  Hysterical 
symptoms  are  in  constant  association  with  phantom  tumors,  and 
these  cases,  in  the  days  of  the  early  ovariotomists,  were  in  sev- 
eral instances  operated  upon  by  mistake. 

The  enlargement  of  the  veins  often  seen  in  the  skin  of  the 
abdomen  in  cases  of  ovarian'  tumor  is  of  no  great  assistance  as 
a  diagnostic  sign,  for  it  is  present  in  almost  every  other  disease 
simulating  ovarian  dropsy.  Any  very  marked  enlargement  of 
the  veins  may,  however,  be  a  reason  for  suspecting  malignant 
disease  if  the  other  indications  be  negative.  In  one  or  two  in- 
stances I  have  seen  this  enlargement  the  only  indication  of  the 
cancer  found  on  opening  the  abdomen. 

As  the  tumor  enlarges,  the  symptoms  become  more  numerous 
and  various;  thus  in  the  pelvis,  by  pressure  on  the  rectum,  blad- 
der, and  nerves,  it  may  give  rise  to  dysuria  or  incontinence,  to 
constipation  or  diarrhoea,  and  to  various  neuralgige.  In  the  ab- 
dominal cavity,  by  pressure  on  the  stomach,  liver,  and  dia- 
phragm, it  produces  very  frequently  nausea  and  vomiting,  and 
distaste  for  food;  in  one  case  in  my  own  experience  it  caused 
jaundice;  and  very  often  difficulty  of  breathing,  amounting  in 
the  latter  stages  to  orthopnoea,  is  induced.  Coincidently  with 
the  production  of  these  visceral  symptoms,  indications  of  great 
systemic  alterations  come  on  gradually,  due  partly  to  direct  in- 
terference with  nutrition  and  partly  to  its  perversion.  Thus  the 
patient  becomes  thinner,  and  the  skin  dry  and  often  hot,  the 
eyes  sink,  and  the  features  become  pinched,  and  then  comes  on 
the  peculiar  expression  of  face  which  has  been  named  the  "  facies 
ovariana."  The  legs  at  this  stage  generally  become  oedematous, 
from  the  mechanical  obstruction  to  the  return  of  the  blood  from 
the  limbs,  and  the  oedema  extends  to  the  vulva  and  over  the 
lower  and  central  walls  of  the  abdomen.  "When  the  tumor  has 
reached  such  extreme  size  as  is  indicated  by  these  symptoms,  if 
then  seen  for  the  first  time,  its  diagnosis  becomes  a  matter  of 
some  difficulty,  even  by  the  careful  consideration  of  its  signs; 
for  it  is  in  the  very  small  and  in  the  very  large  ovarian  tumors 
that  the  diagnosis  is  most  difficult.  In  those  of  medium  size  the 
task  is  much  more  easy. 

The  physical  signs  which  indicate  the  presence  of  an  ovarian 
tumor  come  under  the  notice  of  the  surgeon,  as  a  rule,  only 
when  the  tumor  has  reached  a  size  sufficient  to  have  obliged  it 


OVAKIAN  TUMORS,  COjSTDITIONS  WHICH  SIMULATE  THEM.      193 

to  rise  out  of  the  pelvis,  and  appear  as  an  abdominal  enlarge- 
ment. It  is  often,  however,  necessary  to  determine  the  nature 
of  a  small  pelvic  tumor,  and,  as  I  have  already  said,  to  remove 
it.  Such  a  diagnosis  is  a  matter  of  no  great  difficulty  to  any  one 
accustomed  to  make  the  bimanual  examination,  more  especially 
if  it  be  conducted  while  the  patient  is  under  the  influence  of  an 
anaesthetic.  An  ovarian  tumor  will  be  found  to  be  almost  in- 
variably behind  the  uterus,  that  viscus  being  pressed  forward 
close  to  the  pubic  bone;  and  its  fundus  may,  save  in  excejjtion- 
ally  obese  patients,  be  felt  just  above  the  pubes.  Usually  the 
uterus  can  be  fixed  between  the  two  hands,  and  then  no  doubt 
can  be  entertained  as  to  what  it  is.  Behind  it  is  the  tumor,  and 
if  the  uterus  can  be  moved  independently  of  it,  and  if  the  tumor 
can  also  be  raised  out  of  the  pelvis  independently  of  the  uterus, 
no  doubt  need  be  felt  that  it  is  a  tumor  of  the  ovary  or  of  the 
broad  ligament.  An  absolute  determination  between  these  two 
is  not  a  matter  of  much  importance,  but  it  may  be  made  by  the 
practised  fingers  being  able  to  determine  a  uniform  intensity  of 
the  fluctuation  wave  in  different  diameters  of  the  tumor,  and  by 
this  being  also  distinguished  between  the  two  forefingers  in 
bimanual  examination. 

As  the  tumor  increases  in  size  and  rises  out  of  the  pelvis  it 
becomes  somewhat  more  difficult  to  determine  that  it  is  not  inti- 
mately associated  with  the  uterus.  It  may  be  necessary  to  in- 
troduce the  sound  in  order  to  determine  this  point;  but  this,  as 
a  rule  to  which  I  think  there  can  scarcely  be  an  exception,  ought 
never  to  be  done  at  the  first  examination.  I  have  known  a  mis- 
carriage, in  more  than  one  instance,  brought  on  by  neglect  of 
this  rule  by  very  competent  surgeons.  It  not  unfrequently  hap- 
pens that  menstruation,  or  some  loss  resembling  it,  goes  on  for 
the  first  few  months  of  pregnancy;  and  to  assert  the  diagnosis 
between  early  pregnancy  and  an  ovarian  tumor  just  rising  out 
of  the  pelvis,  at  a  first  examination,  is  a  task  which  only  the 
rash  or  the  greatly  experienced  will  undertake.  If,  with  the 
patient  on  her  back,  one  forefinger  on  the  os  uteri  and  the  other 
on  the  fundus  of  the  tumor,  the  two  be  found  to  embrace  some- 
thing which  moves  en  inasse,  then  it  is,  of  course,  certainly 
uterine.  But  if  the  two  fingers  seem  to  be  in  relation  with  dif- 
ferent structures,  then  the  outside  finger  must  search  for  the 
fundus  uteri,  and  after  it  has  been  found,  and  after  it  has  been 
ascertained  that  the  uterus  is  not  enlarged,  and  then  only,  the 
sound  may  be  introduced  into  the  uterus,  and  its  relation  to  the 
tumor  readily  ascertained.  The  first  matter,  then,  is  to  be  cer- 
tain that  the  tumor  is  not  uterine.  If  it  be  not,  audit  be  rounded, 
elastic,  and  capable  of  being  raised  to  some  extent  out  of  the  pel- 
13 


194  DISEASES   OF   THE   OVARIES. 

vis,  then  it  is  almost  certainly  ovarian.  It  still  mr.y  be  ovarian, 
even  if  fixed  to  the  pelvis,  though  it  is  rare  that  ovarian  tumors 
contract  adhesions  at  such  an  early  stage  of  their  growth.  If 
fixed,  then,  it  may  be  a  hsematocele,  or  an  abscess,  or  a  soft  tu- 
mor growing  from  bone;  but  the  diagnosis  of  all  these  maybe 
greatly  assisted  by  the  previous  history  and  the  general  symp- 
toms. 

Examination  by  the  rectum  will  often  yield  valuable  addi- 
tions to  the  information  obtained  by  vaginal  examination  as  to 
the  relations  of  a  pelvic  tumor,  and  it  may  be  carried  out  accord- 
ing to  Simon's  plan,  by  the  introduction  of  the  whole  hand  into 
the  rectum.  This  should  only  be  done,  however,  under  excep- 
tional circumstances,  when  other  means  have  failed  to  satisfy 
the  mind  of  the  examiner,  and  surgeons  having  large  hands 
should  not  attempt  it.  Personally,  I  have  never  employed  this 
method,  and  I  do  not  think  it  has  met  with  very  general  accept- 
ance. I  saw  Dr.  Simon  perform  it  several  times  at  Heidelberg, 
and  he  informed  me  that  he  never  found  any  ill-effects  from  it. 
I  have  since  heard,  however,  of  many  disasters  from  its  use  in 
this  country,  none  of  which  have  I  seen  published,  and  I  think 
it  had  better  be  dismissed. 

When  an  ovarian  tumor  has  risen  out  of  the  pelvis,  and  has 
as  yet  met  with  none  of  the  accidents  to  which  they  are  liable, 
and  which  lead  to  complications,  its  diagnosis  is  a  matter  of  ease. 
First  of  all,  palpation  will  discover  that  it  is  a  tumor  by  its  re- 
sistance, and  firm  pressure  on  it  with  the  fingers  of  one  hand, 
and  percussion  on  them  with  the  fingers  of  the  other  yielding  a 
dull  note,  will  exclude  the  possibility  of  the  case  being  one  of 
phantom  tumor;  and,  as  the  tumor  pushes  the  intestines  before 
it  upward  and  to  each  side,  in  these  regions  a  tympanic  note 
will  give  the  indications  by  percussion  peculiar  to  uterine  and 
ovarian  tumors,  what  I  have  termed  the  "tympanic  corona." 
It  must  be  remembered,  however,  that  some  intestine  may  have 
slipped  down  in  front  of  an  ovarian  or  uterine  tumor,  or  some 
may  be  adherent  there,  so  as  to  produce  a  note  of  clear  reso- 
nance. This  condition  is,  however,  very  exceptional,  and  if  a 
resonant  note  be  found  in  front  of  the  tumor  the  chances  are 
greatly  against  it  being  ovarian. 

Mr.  Spencer  Wells  has  pointed  out  one  very  exceptional  con- 
dition which  may  completely  baffle  us  in  drawing  conclusions 
from  the  percussion  sign.  I  have  never  seen  it,  am  very  doubt- 
ful about  it,  and  therefore  I  give  at  length  an  extract  from  his 
lectures  on  the  subject : 

"Another  point  of  doubt  and  difficulty  may  arise  from  the  air 
having  entered  an  ovarian  cyst;  for,  as  an  ovarian  cyst  contains 


OVARIAlSr  TUMORS,  CONDITIONS  WHICH  SIMULATE  TJIEM.      195 

a  certain  amount  of  fluid,  it  may  also  contain  gas,  and  either 
the  fluid  is  decomposed  after  tapping,  or  there  may  have  been 
some  possible  communication  set  up  between  the  intestine  and 
the  interior  of  the  cyst.  Sir  Thomas  Watson  records  a  case  in 
which  a  patient  had  a  cyst  filled  alternately  with  fluid  and  witli 
air;  when  the  fluid  collected  to  a  certain  quantity  it  seemed  to 
open  some  valve-like  communication  with  the  intestine,  emptied 
itself,  and  became  filled  with  air.  As  the  fluid  gradually  re- 
formed, the  air  was  displaced,  and  the  same  series  of  changes 
went  through  again.  I  have  known  a  case  in  which  air  dis- 
tinctly entered." 

To  exclude  the  possibility  of  the  tumor  being  uterine,  some 
care  is  necessary;  but  it  is  not  difficult  when  the  educated  touch 
has  determined  that  the  tumor  fluctuates,  and  that,  throughout 
its  extent,  the  peculiar  wave  passes  which  is  found  on  gently 
striking  any  part  of  a  bag  of  fluid  while  the  liand  rests  on  some 
other  part  of  its  circumference.  A  knowledge  of  what  fluctua- 
tion is,  and  what  this  peculiar  thrill  is,  is  not  easily  communi- 
cated by  description,  and  it  requires  long  practice  to  be  able  to 
recognize  it  accurately. 

If  the  wave  be  equally  distributed  in  every  direction  all  over 
a  tumor,  then,  in  all  probability,  it  is  unilocular.  A  multilocular 
tumor,  or  one  composed  of  two  or  three  large  cysts,  may  often 
be  recognized  by  the  practised  fingers  detecting  a  difference  in 
intensity  of  the  wave  along  different  diameters  of  the  tumor. 
There  are  two  conditions,  however,  which  must  be  carefully  ex- 
cluded from  the  possibilities,  and,  just  because  they  are  both  very 
uncommon,  their  probabilities  are  every  now  and  then  over- 
looked. They  are  cystic  diseases  of  the  uterus  and  hydramnios. 
In  the  former,  the  tumor  will  be  found  associated  with  the  uterus, 
the  latter  moving  along  with  the  tumor  when  it  is  moved,  and 
being  dragged  upward  by  it  to  an  extent  that  ought  always  to 
make  us  cautious,  and  warn  us  to  wait  and  watch. 

Finally,  there  is  that  great  aid  to  diagnosis,  the  employment 
of  an  anaesthetic,  without  which,  in  every  case  of  doubt,  no  posi- 
tive opinion  should  be  arrived  at.  When  the  muscles  are  com- 
pletely relaxed  a  great  deal  may  be  determined  which  is  not  pos- 
sible otherwise,  especially  in  the  pelvis. 

I  need  not  say  that  in  all  cases  of  abdominal  tumor  vaginal 
examination  of  the  pelvis  is  of  the  utmost  importance.  As  far 
as  ovarian  or  parovarian  tumors  are  concerned,  the  most  impor- 
tant indication  is  when  a  vaginal  examination  gives  entirely 
negative  results,  that  is,  when  there  is  nothing  felt  in  the  pelvis 
save  the  uterus  in  its  normal  position  and  freely  movable.  We 
may  then  take  it  for  granted  that  the  pelvic  relations  of  the  tu- 


196  DISEASES    OF   THE    OVARIES. 

mor  are  of  the  most  favorable  kind  and  tliat  the  pedicle  is  of 
reasonable  length.  If  the  tumor  is  felt  in  the  pelvis  it  will  gen- 
erally be  behind  the  uterus,  but  this  is  by  no  means  a  uniform 
condition.  The  uterus  may  be  behind  the  tumor,  and  in  that  case 
the  chances  are  that  it  is  sessile  and  a  good  deal  of  trouble  will 
be  experienced  in  dealing  with  the  pedicle.  If  the  cervix  is  found 
to  widen  out  and  be  associated  with  the  tumor  in  every  direction, 
we  have  a  clear  indication  that  the  tumor  is  uterine,  that  is,  it 
may  be  pregnancy  or  a  myoma.  If  the  uterus  is  drawn  up  very 
much  in  front  and  the  posterior  lip  seems  to  be  lost  upon  the 
tumor,  then  we  may  expect  a  tubal  pregnancy.  But  on  the 
other  hand  it  is  not  to  be  assumed  that  a  tumor  felt  in  the  pelvis 
must  necessarily  be  either  ovarian  or  uterine,  for  I  have  felt  in 
the  pelvis  tumors  of  the  kidney,  spleen,  and  liver;  and  then  we 
may  also  have  exceptional  growths,  such  as  malignant  tumors 
of  the  bones  of  the  pelvis  or  of  the  omentum,  and  hydatids  of 
the  peritoneum,  etc.,  etc. 

Auscultation  of  ovarian  tumors  gives  chiefly  negative  signs, 
but  these  are  often  of  value,  as  in  the  case  of  perfect  absence  of 
intestinal  gurgling  over  the  tumor.  A  loud  friction-sound  is 
often  heard,  but  this  is  only  an  indication  of  a  dryness  of  the 
peritoneal  surfaces  where  it  is  heard,  and  there  is  sure  to  be  an 
absence  of  adhesions  at  the  spot.  The  hydatid  fremitus,  as  de- 
scribed by  Mr.  Wells,  I  have  never  been  fortunate  enough  to 
meet  with,  though  I  have  operated  on  a  large  number  of  cases 
of  this  disease. 

Dr.  Le  Double,  of  Tours,  read  a  memoir  at  the  meeting  of  the 
Scientific  Congress  at  Havre  on  this  subject,  but  I  have  not 
gathered  from  it  any  new  facts  of  importance. 

The  best  way  to  learn  to  recognize  fluctuation  is  to  practise 
upon  a  large  bladder  having  a  nozzle  inserted  into  it  so  that  its 
tension  may  be  varied;  for  it  will  be  found  that  there  is  a  con- 
siderable difference  in  fluctuation  according  as  the  cyst  is  tightly 
filled  or  not.  The  sensation  will  also  vary  very  much  accord- 
ing to  the  weight  with  which  the  fingers  of  the  examiner  are 
pressed  upon  the  cyst;  and  the  first  instruction  I  have  always 
to  give  any  one  who  is  observing  abdominal  fluctuation  for  the 
first  time  is  to  press  as  lightly  as  possible  upon  the  skin.  Plac- 
ing the  finger-tips  of  one  hand  gently  upon  the  surface  and  re- 
taining them  there  immovably,  the  fingers  of  the  other  hand 
must  be  tapped  with  exceeding  gentleness  on  the  skin  at  some 
little  distance.  I  lay  particular  stress  upon  the  immobility  of 
the  first  hand  because  it  is  not  unusual  to  see  persons  endeavor- 
ing to  ascertain  the  presence  of  fluid  in  the  abdomen  by  a  sim- 
ultaneous to-and-fro  movement  of  both  hands,  which  can  only 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      197 

result  in  wobbling  the  contents  without  conveying  any  real  im- 
pression to  the  observer's  mind. 

The  first  thing  to  be  learned  is  that  in  the  subcutaneous  layer 
of  any  patient  not  extremely  emaciated  there  may  be  communi- 
cated between  the  two  hands  a  wave  something  like  that  pro- 
duced by  the  presence  of  fluid,  but  having  become  familiar  with 
this  by  practising  upon  a  healthy  abdomen,  especially  that  of  a 
stout  person,  this  difficulty  will  speedily  be  eliminated. 

A  further  test  in  cases  of  doubt  may  be  applied  by  the  method 
first  suggested  by  Sir  James  Paget  of  palpating  first  in  one  di- 
ameter and  then  at  right  angles  to  it,  and  this  test  will  be  per- 
fectly safe  if  the  umbilicus  is  included  in  the  second  diameter; 
for  pseudo-fluctuation  may  be  perceived  in  the  first  instance  but 
will  be  corrected  in  the  second.  As  Sir  James  Paget  has 
pointed  out,  this  phenomenon  is  due  principally  to  the  muscular 
tissue,  which  gives  a  thrill  closely  resembling  the  fluctuation  of 
fluid  across  its  length  but  not  in  the  direction  of  the  fibres.  A 
very  convenient  position  for  studying  this  fact  is  the  calf  of  the 
leg.  Having  made  himself  familiar  with  this  superficial  sub- 
cutaneous wave  the  pupil  will  be  less  liable  to  mistake  it  for  the 
superficial  wave  of  ascitic  fluid,  and  still  less  liable  to  mistake  it 
for  the  deeper  wave  of  the  fluid  of  an  ovarian  or  other  cyst. 

Ascitic  fluid  may  be  generally  recognized  by  the  fact  that  it 
is  associated  with  the  uniform  occurrence  of  a  tympanic  note  on 
percussion;  but  when  there  is  ascitic  fluid  as  well  as  fluid  con- 
tained within  a  cyst,  we  have  a  double  wave  of  fluctuation  ex- 
tremely confusing  but  easily  recognized  by  practised  hands. 
There  is  a  very  simple  and  neat  way  of  confirming  the  value  of 
the  sign  of  percussion  in  such  a  case  which  I  have  had  occasion 
to  practise,  and  which  will  almost  always  decide  between  ascites 
and  ovarian  dropsy  in  such  exceptional  cases.  It  consists  in 
mapping  out  the  marginal  area  of  clear  percussion  note  by  a 
pen-and-ink  line,  and  then  ascertaining  whether  a  clear  note, 
obtained  by  percussing  on  a  finger  laid  gently  on  the  skin  im- 
mediately outside  that  line,  can  be  altered  to  a  dull  note  by  in- 
creasing the  pressure.  If  this  alteration  takes  place  generally 
round  the  line  or  throughout  its  greater  part,  it  may  be  taken  for 
certain  that  an  ovarian  or  parovarian  tumor  is  present.  On  the 
other  hand,  if  there  be  a  clear  note  somewhere  over  the  area  of 
the  swelling  which  is  not  removed  by  firm  pressure,  but  is  rather 
extended  or  intensified,  still  more  if  pressure  bring  out  a  clear 
note  where  dulness  existed  without  it,  then  it  will  be  evident 
that  ascites  is  present,  and  not  an  ovarian  cyst.  The  explana- 
tion of  these  signs  is,  that  pressure  round  the  margin  of  an 
ovarian  tumor  will  bring  it  into  more  extensive  relation  with  the 


198  DISEASES    OF   THE   OVARIES. 

abdominal  wall  by  displacing  tbe  intestines,  and  this  is  most 
easily  accomplished  in  the  epigastrium.  In  the  converse  condi- 
tion, when  a  clear  note  is  produced  by  pressure  in  ascites,  the 
abdominal  wall  is  brought  into  contact  with  floating  intestine, 
the  mesentery  of  which  is  so  short,  and  the  quantity  of  fluid  so 
great,  as  to  keep  the  structures  apart  in  the  absence  of  the  pres- 
sure. We  have,  further,  a  difference  between  the  clear  percus- 
sion notes  of  ascites  and  ovarian  dropsy,  in  that  the  former 
readily  alters  its  position,  always  appearing  at  the  part  of  the 
tumor  highest  in  relation  to  the  patient's  position.  Thus,  in  a 
doubtful  case,  if  there  be  a  corona  of  clearness  above  the  sup- 
posed tumor,  extending  from  the  hepatic  to  the  splenic  regions, 
and  any  alteration  of  position,  such  as  lowering  the  shoulders 
and  raising  the  pelvis,  should  alter  the  position  of  the  area  of 
clearness  to  the  region  of  the  umbilicus,  then  the  case  is  almost 
certainly  one  of  peritoneal  dropsy. 

More  than  once  I  have  met  with  a  case  where  even  this  sign 
failed  me,  and  where  I  have  opened  the  abdomen  to  remove  an 
ovarian  tumor  and  found  only  masses  of  peritoneal  cancer.  The 
reason  of  such  a  mistake  was,  that  the  intestines  were  all  matted 
together  by  growths  in  the  great  omentum,  and  were  di-awn  up 
into  an  arch  under  the  diaphragm.  The  exploratory  incision, 
however,  did  no  harm,  the  patients  recovering  from  it  and  dying 
some  time  after  from  the  extension  of  the  disease.  Additional 
difficulty  was  created  in  one  such  case  by  the  fact  that  the  pa- 
tient had  been  twice  tapped  before  the  operation,  and  no  doubt 
was  entertained  that  a  cyst  had  been  emptied,  and  that  the 
masses  felt  were  smaller  cysts.  I  have  also  operated  on  a  case 
in  Avhich  no  intestinal  note  could  be  obtained  anywhere.  The 
patient  had  suffered  from  recurrent  peritonitis,  and  it  was  evi- 
dent that  the  intestines  were  all  behind  the  tumor.  At  the  op- 
eration this  was  found  to  be  the  case,  and  the  adhesions  were  of 
the  most  formidable  character.  Yet  the  patient  recovered  with- 
out a  bad  symptom. 

The  rapidity  with  which  the  waves  travel  is  governed  by 
three  conditions  chiefly.  First,  the  thickness  of  the  abdominal 
walls,  and  this  will  also  influence  the  sharpness  with  which  the 
wave  is  felt.  The  tension  of  the  cyst  will  also  materially  affect 
the  wave  transit,  for  in  the  tightly  filled  cyst  the  wave  rushes 
along  with  great  rapidity,  while  in  the  flaccid  cyst  it  is  trans- 
mitted much  more  slowly  and  is  so  much  less  easily  perceived 
that  the  unpractised  observer  may  altogether  miss  it.  If  the 
contents  of  the  cyst  are  thick  and  gluey  it  may  be  altogether 
impossible  to  obtain  anything  like  a  distinct  wave  of  fluctuation, 
and  there  are  many  cases  of  really  solid  tumors,  more  particu- 


OVARIAN  TUMOESj  CONDITIONS  WHICH  SIMULATE  THEM.      199 

larly  the  oedematous  variety  of  uterine  myoma,  which  are  suf- 
ficiently soft  to  give  a  wave  of  fluctuation  which  makes  it  im- 
possible to  discriminate  them  from  ovarian  cystomata  with 
gluey  contents.  In  fact  I  do  not  know  anything  more  difficult 
to  teach  than  the  many  facts  about  this  sign  of  fluctuation.  I 
do  not  know  anything  requiring  longer  practice  and  greater 
variety  of  experience  for  being  perfectly  learned ;  but  I  also 
know  nothing  giving  greater  diagnostic  power  when  the  fingers 
have  been  sufficiently  trained  to  perceive  its  differences.  Thus, 
given  a  case  of  ovarian  tumor  in  a  young  woman  a.nd  another 
case  of  advanced  pregnancy,  the  practised  fingers  alone,  without 
any  question  being  asked,  without  a  vaginal  examination  being 
even  proposed,  and  without  the  use  of  the  stethoscope,  will  in 
the  majority  of  cases  at  once  be  able  to  make  an  exact  diagnosis; 
while  in  the  case  of  a  large  uterine  myoma,  the  mere  sense  of  re- 
sistance upon  the  first  impact  of  the  hand  is  often  enough  to  de- 
termine the  nature  of  the  case.  This  "  sense  of  resistance"  is  a 
thing  quite  impossible  to  teach.  I  saw  it  first  practised  by  Dr. 
Warburton  Begbie,  and  have  seen  him  diagnose  accurately  and 
by  it  alone  between  an  effusion  of  fluid  in  the  pleura  and  con- 
solidation of  the  lung.  Similarly  in  the  abdomen  this  sign  is 
nearly  always  enough  to  enable  me  to  discriminate  between 
pregnancy,  an  ovarian  tumor  and  a  solid  mass,  though  of  course 
I  should  never  dream  of  trusting  to  it  alone. 

Of  a  similar  character  is  the  sign  to  which  French  writers  have 
given  the  term  ballottement.  This  is  not  confined  in  its  useful- 
ness by  any  means  to  the  determination  of  pregnancy.  In  a  case 
where  there  is  an  abdominal  tumor  surrounded  by  ascitic  fiuid, 
the  latter  may  be  easily  recognized  by  the  sign  of  fluctuation, 
but  the  tumor  may  escape  observation  if  an  effort  be  not  made 
to  discover  its  hallottement.  It  is  my  uniform  practice,  therefore, 
in  examining  an  abdomen  in  which  I  am  satisfied  of  the  presence 
of  ascitic  fluid,  to  place  the  fingers  of  one  hand  upon  the  skin 
very  lightly,  and  then  with  a  steady  and  somewhat  rapid  move- 
ment downward  the  ascitic  fluid  is  made  to  move  away,  and  if 
there  be  a  tumor  the  fingers  come  promptly  in  contact  with  it 
and  convey  a  sensation  which  cannot  be  mistaken.  In  cases  of 
doubtful  pregnancy  this  sign  is  well  enough  known,  and  there, 
of  course,  it  is  the  liquor  amnii  which  is  displaced  by  the  sudden 
movement  of  the  foetus  which  is  felt.  This  ballottement  may  be 
determined  through  the  abdominal  walls  with  quite  as  good  ef- 
fect as  through  the  vaginal  cul-de-sac.  If  the  fluid  outside  the 
cyst  be  small  in  quantity,  its  diagnosis  is  of  no  great  conse- 
quence ;  but  if  large,  its  non-recognition  may  lead  to  serious 
mistakes.     For  instance,  in  one  of  my  cases  I  satisfied  luyself 


200  DISEASES   OF   THE   OVARIES. 

that  there  was  an  ovarian  tumor  from  the  signs  given  by  per- 
cussion, and  that  there  was  evidently  some  ascites  from  the 
double  wave  of  fluctuation.  The  patient  was  of  an  enormous 
size,  and  the  growth  had  not  existed  for  more  than  six  months. 
It  was  a  grave  question  whether  I  had  to  deal  with  a  multilocu- 
lar  tumor  having  one  or  two  very  large  cysts  and  a  small  quan- 
tity of  ascitic  fluid,  or  with  a  small  tumor  and  a  large  quantity 
of  ascitic  fluid.  The  only  method  of  deciding  the  question  would 
have  been  to  tap  the  abdomen  above  the  tumor  by  my  blunt  tro- 
car, and  to  have  evacuated  the  ascitic  fluid  only  ;  but  to  this  the 
patient  would  not  accede,  and  I  had  to  begin  the  operation  in 
serious  doubt.  The  result  showed  that  the  plan  referred  to  would 
have  been  a  wise  one,  for  it  proved  to  be  a  comparatively  small 
tumor  with  an  enormous  ascitic  collection,  all  the  intestines  hav- 
ing been  pushed  above  the  tumor.  There  are  some  minor  signs 
which  often  serve  to  indicate  the  presence  of  ascites  to  any 
marked  extent,  such  as  the  protrusion  of  fluid  through  the  om- 
phalic ring,  carrying  in  front  of  it  a  layer  of  peritoneum  like  the 
finger  of  a  glove.  The  uniformity  of  the  enlargement  by  ascitic 
fluid  is  greater  than  that  produced  by  ovarian  dropsy,  though  in 
the  case  just  referred  to  this  indication  failed  me  ;  for  it  was  the 
Avant  of  symmetry  in  the  measurement  which  suggested  that  the 
chief  cause  of  the  enlargement  was  cystic.  The  readiness  of 
alteration  of  the  form  usual  to  an  abdomen  distended  by  perito- 
neal dropsy  was  also  absent ;  for,  in  whatever  position  the  pa- 
tient lay,  the  same  outlines  were  preserved  ;  and  the  greatest 
proportional  increment  of  measurement  had  occurred  between 
the  umbilicus  and  the  pubes.  This  peculiarity  is  usually  an  in- 
dication of  ovarian  cysts  or  of  uterine  tumors. 

I  have  already  uttered  a  warning,  which  I  think  it  neces- 
sary to  repeat,  concerning  the  use  of  the  sound  ;  and  here  I  may 
introduce  the  account  of  a  very  singular  experience  in  which 
the  use  of  the  sound,  instead  of  being  an  assistance,  might  have 
led  me  into  a  very  serious  mistake,  had  I  not  been  familiar 
with  the  fact  that  every  now  and  then  a  case  occurs  in  which 
the  fundus  uteri  is  perforated  by  the  sound  while  it  is  being 
used  in  an  ordinary  way  by  one  quite  accustomed  to  its  use  and 
without  any  undue  force.  Such  perforations  never  do  any  harm, 
and  I  used  to  see  tlicm  often  when  I  used  the  sound  a  good  deal, 
but  now  that  I  use  it  hardly  at  all  I  have  not  seen  one  for  a  very 
long  time. 

Some  years  ago  I  drew  attention  to  cases  of  persistent  metro- 
peritoneal  fistula  in  which  the  condition  has  been  one  of  inter- 
est only  on  account  of  its  curiosity,  but  in  the  following  case  it 
presented  features  of  great  importance  in  the  diagnosis  of  an 


OVAEIAlSr  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      201 

ovarian  tumor.     S.  W ,  aged  forty-nine,  and  unmarried,  was 

sent  to  me  from  a  distance  in  September,  1874,  on  account  of  an 
abdominal  enlargement  which  had  been  in  progress  for  three 
months,  and  had  reached  a  considerable  size.  The  parietes  were 
extremely  thin,  and  the  wave  of  fluctuation  was  everywhere  ex- 
tremely vivid.  Behind  the  uterus  was  a  round  nodular  mass, 
freely  movable,  and  the  sound  readily  entered  the  uterus  for 
three  inches.  I  diagnosed  ovarian  dropsy,  and  admitted  her 
into  the  hospital  for  the  purpose  of  removing  the  tumor. 

At  a  consultation,  held  on  October  8th,  some  doubt  was  enter- 
tained by  some  of  my  colleagues  that  it  might  be  a  case  of  peri- 
toneal dropsy,  and  to  assist  the  diagnosis  the  sound  was  intro- 
duced by  Mr.  E,oss  Jordan.  It  readily  passed  in  seven  inches 
toward  the  left  side,  though  there  was  absolutely  no  force  used 
in  its  introduction,  the  instrument  seeming  to  slip  in  most  easily. 
I  at  once  expressed  my  opinion  that  the  uterus  had  been  perfo- 
rated, and  with  the  consent  of  my  colleagues  I  proceeded  with 
the  operation.  The  tumor  was  removed  without  difficulty,  and 
the  nodular  mass  behind  the  uterus  was  found  to  be  a  small 
fibroid  growth  in  the  fundus.  It  "was  the  right  ovary  which  was 
removed,  the  left  being  quite  healthy  ;  and  as  the  pedicle  was 
very  short,  and  the  uterus  somewhat  dragged  upon,  I  did  not 
think  myself  justified  in  endeavoring  to  gratify  my  curiosity  by 
looking  for  the  point  of  perforation.  From  the  position  of  the 
fibroid,  however,  I  am  certain  that  the  aperture  must  have  been 
situated  in  the  anterior  wall,  for  the  fundus  was  completely  retro- 
flexed,  both  Fallopian  tubes  being  carried  with  it.  It  is  proba- 
ble that  the  anterior  wall  had  become  very  attenuated,  or  even 
completely  perforated,  from  being  stretched  over  the  fibroid  by 
the  retroflection,  this  latter  being  evidently  due  mainly  to  the 
pressure  of  the  tumor  from  above. 

Whether  Mr.  Jordan  made  the  perforation  or  not,  it  made  no 
difference  to  the  progress  of  the  case,  for  she  got  well  without  a 
bad  symptom,  and  went  home  on  the  twentieth  day.  She  called 
on  me  eight  weeks  after  the  operation  with  the  wound  almost 
healed.  I  passed  the  sound  very  cautiously  into  the  uterus,  and 
found  that  it  readily  entered  three  inches,  and  then  met  with  the 
usual  obstruction.  I  happened,  however,  to  move  its  point  about 
a  little,  and  found  that  toward  the  left  side  of  the  cavity  it 
slipped  through  a  hole,  and  made  itself  immediately  perceptible 
under  the  integuments  to  the  left  of  the  cicatrix.  The  right 
cornu  of  the  uterus  was  tilted  upward  toward  the  wound,  on  ac- 
count of  the  adhesion  of  the  pedicle,  and  I  know  that  the  sound 
could  not  have  passed  through  the  Fallopian  tube  on  that  side, 
for  it  had  been  embraced  by  the  clamp ;  while  the  thinness  of 


202  DISEASES    OF   THE    OVARIES. 

the  abdominal  walls  and  the  fixidity  of  the  uterus  enabled  me  to 
determine  that  the  sound  had  clearly  passed  through  the  ante- 
rior wall  somewhere  to  the  left  of  the  middle  line  of  the  organ. 

In  addition,  therefore,  to  the  interesting  fact  which  my  for- 
mer cases  clearly  established,  that  we  may  have  permanent 
communications  formed  between  the  peritoneal  cavity  and  the 
cavity  of  the  uterus  other  than  those  of  the  oviducts,  and  with- 
out any  deleterious  results,  we  have  in  this  case  the  further  fact 
of  great  clinical  importance,  that  these  abnormal  apertures  may 
be  the  cause  of  confusion  in  diagnosis.  If  I  had  not  been  firmly 
convinced,  from  the  physical  signs,  that  my  patient  really  suf- 
fered from  an  ovarian  tumor,  the  passage  of  the  sound  inward 
for  seven  inches,  in  tlie  hands  of  one  so  careful  and  so  skilled  as 
Mr.  Jordan,  would  have  so  staggered  me  that  I  should  have 
fallen  into  error. 

Familiarity  with  the  somewhat  common  occurrence  of  such 
apertures,  however,  enabled  me  to  have  the  courage  of  my 
opinions. 

In  my  earlier  practice  I  placed  considerable  reliance  upon 
tapping  as  a  means  of  diagnosis  in  abdominal  tumors,  but  fur- 
ther experience  has  led  me  to  distrust  it.  Some  of  my  reasons 
for  distrusting  tapping  will  be  given  at  greater  length  in  another 
chapter  and  others  I  have  already  discussed. 

In  cases  where  there  is  ascitic  fluid  its  removal  may  indeed 
help  us  to  map  out  the  position  and  size  of  a  tumor  with  greater 
accuracy,  or  the  removal  of  the  fluid  from  a  cyst  may  help  us 
to  determine  that  it  is  parovarian,  or  that  it  is  ovarian,  from 
the  fact  that  other  cysts  or  solid  matter  were  left  behind;  but 
beyond  this  tapping  helps  us  but  little.  It  serves  in  no  way  to 
clear  up  the  nature  of  a  doubtful  tumor,  nor  does  it  reveal 
what  the  intimate  relations  of  that  tumor  may  be.  The  opera- 
tion has  its  own  special  risks,  and  our  more  recent  experience 
shows  that  these  risks  are  greater  than,  or  at  least  as  great  as, 
those  of  a  simple  exploratory  incision.  I  therefore  prefer  the 
latter  in  all  cases,  for  if  we  can  do  no  more  than  relieve  the  pa- 
tient of  a  quantity  of  ascitic  fluid,  or  of  the  contents  of  one  or 
more  major  cysts,  we  can  do  this  far  more  effectually  by  a  small 
exploratory  incision  than  by  the  wound  of  a  trocar,  and  with 
quite  as  little  risk. 

Of  the  occasional  misfortunes  which  follow  tapping,  I  had  a 
very  notable  instance  in  the  case  of  a  patient  sent  to  me  some 
years  ago  by  Dr.  Laidler,  of  Stockton-on-Tees.  She  was  of  enor- 
mous size,  so  that  it  was  advisable  to  tap  her  before  removing 
the  tumor.  Unfortunately,  the  cyst-walls  were  permeated  by 
large  venous  sinuses,  and  one  of  these  was  injured  by  the  trocar, 


OVAEIAN  TUMOES,  CONDITIONS  WHICH  SIMULATE  THEM.     203 

SO  that  several  pounds  of  blood  poured  into  the  cavity  of  the 
emptied  cyst,  and  the  result  was  unfavorable  to  the  success  of 
the  subsequent  ovariotomy.  Besides  such  an  exceptional  risk  as 
this,  there  is  the  possibility  of  suppuration  of  the  cyst  after  taj)- 
ping,  and  the  infection  of  the  peritoneum  by  its  septic  contents. 
Finally,  by  means  of  an  exploratory  incision,  which  need  not 
as  a  rule  be  more  than  an  inch  and  a  half  or  two  inches  long,  we 
can  ascertain  absolutely  the  nature  of  the  tumor  and  very  many 
of  its  relations,  and  we  may  generally  obtain  information  con- 
cerning it  altogether  beyond  the  reach  of  a  tapping.  This  latter 
operation,  therefore,  I  have  almost  entirely  excluded  from  my 
practice  for  any  purpose  of  diagnosis,  and  it  is  now  only  used  for 
relief  in  those  cases  where  removal  of  the  tumor  is  impossible. 
When  it  is  absolutely  necessary  to  tap,  the  operation  is  best  per- 
formed by  a  trocar  which  I  have  devised,  having  a  steel  point 
with  a  chisel  edge,  which  is  almost  blunt.  The  patient  having 
been  placed  in  a  convenient  position,  a  puncture  is  made  by  an 


Fig.  29. 

ordinary  lancet  into  the  cyst,  and  the  trocar  is  made  to  follow 
the  track  of  the  lancet.  The  trocar  is  so  simple  that  it  never  can 
be  out  of  order;  it  forms  a  solid  rod,  which  is  extremely  useful 
as  a  probe,  and  its  point  is  sharp  enough  to  penetrate  an  inner 
cyst,  and  yet  so  blunt  as  to  be  incapable  of  mischief  save  in  the 
hands  of  the  clumsy  or  the  careless.  Great  care  should  always 
be  taken  to  empty  completely  the  cyst  which  is  tapped,  and  to 
prevent  the  admission  of  air,  and  for  this  latter  point  the  perfect 
solidity  of  my  trocar  is  the  most  absolute  guarantee. 

Tapping  by  the  vagina  was  an. operation  a  good  deal  in  vogue 
about  eight  or  ten  years  ago,  and  I  have  had  two  cases  in  which 
cysts  of  some  kind  were  permanently  cured  by  this  means;  but 
as  it  is  by  no  means  always  attended  with  good  results,  I  have 
almost  discontinued  it.  I  have  known  death  occur  three  times 
after  it,  and  I  may  state  as  my  general  conclusion  that  I  have  a 
growing  distrust  of  tapping  of  any  kind,  either  by  the  aspirator 
or  the  trocar,  and  in  all  cases  where  treatment  is  or  may  be  an 
object,  as  well  as  diagnosis,  I  infinitely  prefer  an  abdominal 
section. 

The  diagnosis  of  the  variety  of  tumor  in  each  case  is  of  im- 


204  DISEASES    OF   THE    OVARIES. 

portance  in  guiding  us  to  its  treatment;  therefore  it  is  not  for 
the  mere  exercise  of  ingenuity  that  I  recommend  every  practi- 
tioner dealing  with  a  case  of  ovarian  tumor  to  exhaust  every 
point  on  which  I  have  dwelt,  together  with  many  others  to  which 
I  have  not  alluded,  but  which  the  individual  peculiarities  of  each 
case  and  his  own  personal  shrewdness  may  suggest.  Above  all, 
let  me  again  urge  the  necessity  of  reasoning  by  exclusion,  and  of 
making  repeated  examinations  at  intervals  before  any  certainty 
of  diagnosis  is  felt.  Three  times  it  has  occurred  to  me  to  remove 
ovarian  tumors  which  had  hastily  been  set  down  at  an  early 
period  of  their  history  as  floating  kidneys,  that  diagnosis  hav- 
ing been  made  in  all  three  cases  because  the  wish  was  father  to 
the  thought,  and  because  the  practitioners  who  made  it  had  not 
learned  the  value  of  patience.  It  is  this  want  of  patience  that  is 
to  blame  for  those  melancholy  instances  of  blunders,  altogether 
unpardonable,  where  the  abdomen  has  been  opened  in  cases  of 
normal  pregnancy  mistaken  for  ovarian  tumors. 

There  are  many  conditions  which  simulate  ovarian  tumors 
besides  those  already  alluded  to,  and  I  propose  now  to  devote 
some  space  to  the  consideration  of  as  many  of  these  as  have  oc- 
curred to  me  in  practice.  I  have  no  doubt  there  are  others  which 
may  yet  arise  in  my  experience,  but  I  think  the  list  I  am  about 
to  give  is  a  fairly  inclusive  one. 

In  the  earlier  experiences  of  abdominal  surgery  many  cases 
occurred  in  which  an  operation  was  performed  for  the  removal 
of  an  ovarian  tumor  and  no  tumor  found  ;  that  is  to  say,  where 
there  was  no  condition  whatever  to  justify  the  mistake.  During 
the  last  twenty  or  twenty-five  years,  however,  I  have  not  heard 
of  any  instances  of  this  kind,  indeed  the  introduction  of  anaesthet- 
ics has  rendered  such  a  misfortune  all  but  impossible.  We  can 
easily  understand  how  such  mistakes  as  those  so  candidly  nar- 
rated by  Mr.  Lizars  could  occur.  We  can  only  admire  the  frank- 
ness with  which  he  published  them,  and  acknowledge  the  great 
service  the  publication  rendered  to  his  successors.  It  is  a  trite 
saying,  but  one  worthy  of  frequent  repetition,  that  we  learn  a 
great  deal  more  from  our  blunders  than  we  do  from  our  suc- 
cesses. 

Before  the  introduction  of  anaesthetics  the  most  likely  condi- 
tion to  give  rise  to  such  a  mistake  was  that  singular  disease  known 
as  phantom  tumor  or  phantom  pregnancy,  to  which  the  name  of 
pseudocyesis  has  been  given  by  Goode.  This  singular  disease  is 
certainly  an  affection  of  the  nervous  system,  and  lies  in  that 
border-land  which  exists  between  hysteria  and  insanity,  and 
where  everything  in  the  way  of  explanation  consists  merely  of 
guesswork.     There  can  be  no  doubt  that  whatever  may  be  the 


OVARIAlSr  TUMORS,   CONDITIONS  WHICH  SIMULATE  THEM.      205 

mechanism  of  this  disease,  its  immediate  exciting  cause  is  inti- 
mately associated  with  the  ovaries,  as  indeed  is  the  whole  group 
of  hysterical  diseases.  We  know,  however,  that  these  affections 
are  by  no  means  unknown  in  the  male  sex,  and  I  have  seen  a 
marked  case  of  phantom  tumor  in  a  male,  and  singularly  enough 
a  medical  man  was  the  victim  of  the  fancy.  Mr,  Spencer  Wells 
{British  Medical  Journal,  June,  1878)  says  he  saw  a  phantom  tu- 
mor in  a  soldier  who  came  down  from  the  Crimea  to  Smyrna 
with  an  abdominal  enlargement  which  entirely  disappeared 
when  the  man  was  narcotized  with  chloroform.  Perhaps  this 
was  a  case  of  malingering. 

Simpson,  quoting  Harvey  and  giving  also  his  own  experi- 
ence, tells  us  that  symptoms  such  as  we  find  in  these  cases  are 
to  be  observed  in  cows  and  bitches ;  and  doubtless,  if  accurate 
observations  were  to  be  made  on  these  animals  so  affected,  some 
kind  of  explanation  would  be  arrived  at.  That  the  symptoms 
are  due  to  a  perverted  intelligence,  or  a  mere  desire  to  defraud, 
is  not  an  explanation  which  would  apply  to  many  cases  which 
have  come  under  my  own  observation,  and  it  could  scarcely  be 
urged  in  the  case  of  animals.  I  have  failed,  however,  to  find  that 
in  cows  or  bitches  any  of  the  imitative  symptoms  have  often  been 
observed;  that  is  to  say,  such  symptoms  as  distention  of  the  abdo- 
men seldom  occur.  The  signs  of  the  spurious  pregnancy  in  them 
consist  in  the  refiex  phenomena  which  accompany  true  preg- 
nancy, and  this  points  conclusively  to  some  false  start  given  to 
the  refiex  mechanism  which  connects  the  ovaries  and  uterus 
with  their  subsidiary  organs  and  the  system  generally. 

Dr.  S.  Haughton,  F.RS.,  made  a  communication  to  the  Dub- 
lin Obstetrical  Society  on  February  7,  1880,  on  a  case  of  phantom 
tumor  in  an  ass.  Having  purchased  a  fine  specimen  of  a  rare 
variety  of  zebra,  he  was  anxious  to  provide  a  suitable  partner 
for  him  ;  he  therefore  obtained  a  healthy  three-year-old  virgin 
ass.  It  was  necessary  to  have  a  virgin,  as  it  was  known  that 
the  first  intercourse  gave  a  stamp  to  the  subsequent  progeny. 
Frequent  and  apparently  satisfactory  intercourse  took  place  be- 
tween the  two.  The  ass  came  into  season  at  intervals  of  five 
weeks,  and  remained  .so  from  ten  to  fourteen  days,  and  its  period 
of  utero-gestation  was  eleven  months.  It  was  therefore  easy  to 
discern  when  the  animal  was  in  foal.  After  six  weeks,  the  ass 
began  to  enlarge  visibly,  and  a  man  much  accustomed  to  the 
breeding  of  horses  declared  that  he  could  "feel  the  foal  inside 
her."  The  eleven  months  expired,  and  the  ass  came  into  season 
again  without  having  given  birth  to  a  foal.  After  a  lapse  of  four 
months  she  was  again  given  the  zebra,  and  again  she  swelled, 
continued  so  for  eleven  months,  and  again  gave  birth  to  noth- 


206  DISEASES   OF  THE   OVARIES. 

ing.  In  this  case  he  considered  that  the  mental  element  might 
be  disregarded,  for  the  ass  could  have  no  object  in  deceiving,  and 
her  illusion  of  being  in  foal  influenced  her  physiological  condi- 
tion, for  her  mammary  glands  were  enlarged,  and  when  the 
supposed  pregnancy  was  over  they  subsided  with  the  abdominal 
enlargement. 

The  great  majority  of  cases  of  phantom  tumor  are  really  in- 
stances of  spurious  pregnancy  incompletely  developed;  indeed,  I 
am  not  quite  sure  but  that  every  case  really  is  so;  those  about 
which  I  have  doubt  being  of  a  class  which  are  certainly  hysteri- 
cal, which  have  no  other  sign  than  abdominal  distention,  and 
which  seem  to  me  perfectly  analogous  to  crib-biting  among 
horses.  I  have  seen  a  suflScient  number  of  these  to  be  able  gen- 
erally to  distinguish  them  as  they  enter  the  consulting-room,  by 
the  one  sign  which  can  always  be  heard,  loud  intestinal  gur- 
glings. These  gurglings  are  due  to  the  swallowing  of  air  which 
the  patient  indulges  in  for  a  few  minutes  before  she  visits  the 
surgeon,  and  she  generally  begins  the  consultation  by  attracting 
attention  to  them  and  to  her  large  size.  The  increase  in  size  is 
partly  due  to  the  spurious  flatulence  and  partly  to  the  peculiar 
muscular  rigidities  which  these  patients  indulge  in.  If  the  pa- 
tient is  kept  engaged  in  conversation  for  fifteen  or  twenty  min- 
utes, without  an  opportunity  of  renewing  her  air  supply,  the 
gurglings  will  entirely  cease  and  she  will  markedly  diminish  in 
size.  Physical  examination,  especially  under  an  anaesthetic,  at 
once  confirms  the  spurious  nature  of  the  abdominal  distention. 
In  these  cases  there  is  usually  no  attempt  on  the  part  of  the  pa- 
tient to  induce  the  surgeon  to  believe  that  she  is  pregnant,  or 
even  that  she  has  a  tumor,  and  the  belief  that  a  deliberate  and 
voluntary  fraud  is  intended  is,  I  think,  to  be  justified  only  in  ex- 
ceptional cases.  The  object  seems  really  to  be  that  of  gratifying 
that  insatiable  love  of  attracting  attention  so  deeply  rooted  in  the 
female  mind,  a  weakness  which  is  at  the  bottom  of  ninety-nine 
cases  of  hysteria  out  of  every  hundred;  and  it  must  be  borne  in 
mind  that  this  desire  is  characteristic  of  many  forms  of  insanity 
in  men  as  well  as  in  women.  The  majority  of  cases  of  eccentric 
hysteria  occur  in  women  to  whom  nature  has  denied  the  exter- 
nal attractions  of  beauty,  or  in  whom  there  is  not  the  compensa- . 
tion  of  a  refined  and  cultured  intellect.  It  is  therefore  in  neg- 
lected and  ill-educated  women  that  these  objectionable  forms  of 
liysteria  are  chiefly  to  be  met  with.  I  have  seen  the  kind  I  am 
now  speaking  of  imitated  by  crib-biting  mares  and  geldings  very 
closely,  the  best  instance  having  occurred  in  a  mare.  She  was . 
generally  required  to  go  out  at  a  particular  time  of  day,  and  as 
that  hour  approached,  if  she  could  succeed  in  getting  a  hold  of 


OVAKTATT  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      207 

any  fixed  object  with  her  teeth  she  would  secure  a  quiet  day  in 
the  stable  by  rendering  herself  quite  unfit  for  work  for  many 
hours.  She  would  swallow  large  gulps  of  air,  so  that  the  disten- 
sion looked,  to  those  unaccustomed  to  it,  almost  like  the  last 
stage  of  a  peritoneal  dropsy,  and  the  intestinal  gurglings  could 
be  heard  at  many  yards  distant.  In  a  few  hours  she  would  be 
well  again  and  ready  for  work;  bat  nothing  could  prevent  her 
succeeding  in  her  trick  unless  care  was  taken  to  have  nothing 
about  upon  which  she  could  fix  her  teeth. 

Women  who  indulge  in  this  objectionable  habit  are  nearly 
always  sterile,  though  I  can  call  to  mind  two  cases  in  mothers 
of  large  families.  It  is  by  no  means  confined  to  any  jjeriod  of 
life,  as  I  have  seen  it  in  very  young  and  in  very  old  women. 

Between  this  group  and  those  in  which  there  is  always  pres- 
ent a  distinct  conviction  that  they  have  a  tumor,  there  is  no  de- 
fined line,  but  they  are  generally  women  of  the  same  type. 
They  do  not  usually,  however,  have  the  gurglings,  the  disten- 
sion being  produced  entirely  by  some  peculiar  muscular  fixation, 
in  which  probably  the  diaphragm  is  the  chief  factor.  In  order 
to  distend  the  walls  of  the  abdomen,  the  first  step  is  to  fix  the 
diaphragm  at  as  low  a  level  as  possible;  and  after  this  is  done, 
breathing  can  be  carried  on  by  the  ribs  alone.  The  time  through 
which  this  kind  of  respiration  can  be  employed  is  very  brief  in 
men,  but  is  practically  unlimited  in  women,  owing  to  the  pecu- 
liar superior  costal  method  of  breathing  which  exists  in  them. 
After  fixing  her  muscles  in  this  way,  a  woman  has  only  to  throw 
her  shoulders  back  and  her  pelvis  forward,  and  if  her  clothes 
are  loose  she  at  once  presents  the  appearance  of  pregnancy;  and 
in  these  cases,  if  the  confidence  of  the  patient  be  sufficiently 
reached,  it  will  always  be  found  that  there  is  either  a  hidden  de- 
sire or  a  concealed  dread  of  pregnancy.  Generally,  there  is 
some  little  sign,  or  a  group  of  symptoms,  which  gives  coloring 
to  the  suspicion;  such  as  morning  sickness,  pain  in  the  breasts, 
flow  of  milk,  or  arrest  of  the  menses;  but  in  those  cases  where 
there  is  no  expressed  belief  in  the  existence  of  pregnancy,  the 
history  of  the  symptoms  given  seldom  leads  up  to  that  supposi- 
tion, and  the  patients  are  generally  very  reticent  in  giving  their 
own  impression.  Between  this  second  group  of  cases  and  the 
third,  in  which  I  class  those  in  which  the  belief  in  pregnancy  is 
expressed,  and  both  its  symptoms  and  signs  given  with  more  or 
less  completeness  and  without  hesitation,  there  is  no  well-defined 
distinction;  for  cases  present  themselves  in  which  the  condition  is 
not  sufficiently  complete  to  place  them  under  the  heading  of  spuri- 
ous pregnancy,  and  yet  where  there  is  evidently  a  belief  on  the 
part  of  the  patient  that  there  is  something  more  than  a  swelling. 


208  DISEASES    OF   THE    OVAllIES. 

A  "well-marked  case  of  spurious  pregnancy,  with  its  train  of 
imaginary  symptoms  well  described,  and  its  reflex  phenomena 
well  developed,  is  one  of  the  most  singular  experiences  any  one 
can  have,  and  is  most  bewildering  to  those  unaccustomed  to 
physical  examination  of  the  pelvis.  It  is  by  no  means  confined 
to  women  at  the  climacteric,  as  many  authors  seem  to  have  taken 
for  granted  without  having  properly  analyzed  the  facts  ;  and  it 
is  not  even  confined  to  married  women,  or  such  as  have  engaged 
in  sexual  functions  without  being  married  ;  for  I  have  seen  a 
very  well-marked  case  in  a  young  woman,  twenty-two  years  of 
age,  who  presented  all  the  usual  and  most  trustworthy  features 
of  virginity. 

There  is  some  peculiar  nervous  machinery  put  in  action  the 
moment  a  fertilized  ovum  becomes  attached  to  the  uterine  or 
tubal  mucous  surface,  and  that  machinery  sometimes  gets  a  false 
start.  How  this  occurs,  we  do  not  know,  but  the  result  is  the 
appearance  of  all  the  symptoms  without  the  reality  of  pregnancy. 

One  of  the  most  perfect  cases  of  phantom  pregnancy  or  pseu- 
docyesis  which  I  have  ever  met  with,  was  one  I  saw  in  consul- 
tation with  Dr.  Charles  Warden  and  Mr.  Machin,  of  Erdington. 
The  patient  was  thirty-two  years  of  age,  had  been  married  eleven 
years,  and  had  menstruated  with  perfect  regularity  until  June, 
1872.  Menstruation  was  then  suddenly  and  entirely  arrested, 
she  slowly  increased  in  size,  and  had  morning  sickness  and 
many  other  symptoms  of  pregnancy.  The  breasts  enlarged,  she 
described  the  sensations  of  quickening,  and  she  engaged  Mr. 
Machin  to  attend  her  in  the  confinement  she  expected  in  March. 
ISTothing,  however,  came  of  it.  When  I  saw  her  in  the  follow- 
ing May  she  presented  all  the  appearances  of  being  pregnant  at 
the  full  time,  the  breasts  containing  quite  an  abundant  supply 
of  milk,  and  the  question  to  be  considered  was,  had  she  an  extra- 
uterine pregnancy?  As  the  uterus  was  perfectly  normal,  hav- 
ing no  tumor  of  any  kind  in  association  with  it,  this  suspicion 
Avas  at  once  dispelled  ;  and  on  placing  her  completely  under  the 
influence  of  ether  it  became  at  once  apparent  that  the  preg- 
nancy was  a  phantom,  which  ultimate  test  for  pseudocyesis  is 
one  of  the  many  triumphs  of  gynaecology  due  to  the  genius  of 
Simpson.     This  patient  was  in  the  same  condition  in  1879. 

Another  condition  which  frequently  gives  rise  to  the  suspi- 
cion that  the  patient  is  suffering  from  a  tumor,  and  therefore,  of 
course,  most  probably  an  ovarian  tumor,  is  the  curiously  rapid 
growth  of  omental  fat  which  many  women  put  on  at  the  climac- 
teric period.  Only  a  few  days  ago  a  remarkable  instance  of  this 
occurred  in  my  experience,  the  description  of  which  will  serve 
for  all  I  have  to  say  upon  this  subject. 


OVARIAN  TUMORS,   CONDITIONS  WHICH  SIMULATE  TIIEM.      209 

A  lady  was  brought  to  me  from  a  distance  by  her  medical 
attendant,  who  was  a  gentleman  of  exceptional  experience 
and  ability,  but,  of  course,  like  other  men  engaged  in  general 
practice  in  the  country,  he  had  but  very  occasional  opportunities 
for  obtaining  experience  in  the  diagnosis  of  abdominal  tumors; 
and,  as  he  frankly  told  me,  he  knew  very  little  about  them.  He 
brought  his  patient  to  me  because  he  was  in  doubt,  and  there 
was  no  discredit  due  to  him  by  reason  of  his  difiBculty.  The  pa- 
tient was  forty-seven  years  of  age,  and  for  about  a  year  her  men- 
struation had  become  irregular,  her  abdomen  had  increased  very 
much  in  size,  and  she  had  lost  flesh  in  the  face  and  limbs.  Her 
arms  bore  distinct  evidence  of  this,  for  the  subcutaneous  fat  had 
disappeared  from  them  and  the  skin  was  wrinkled  and  flabby. 
Her  abdomen  was  large,  and,  as  she  said,  dresses  she  could  wear 
only  a  few  months  before,  she  was  now  wholly  unable  to  put  on. 
As  she  lay  on  the  couch  the  appearance  was  certainly  that  of  an 
abdominal  tumor,  but  the  moment  I  touched  the  abdomen  and 
felt  the  tight  condition  of  the  skin,  I  suspected  what  I  had  to 
deal  with.  The  layer  of  subcutaneous  fat  there  was  extremely 
thick,  for  on  taking  up  a  handful  of  the  skin  it  was  found  to  in- 
clude considerably  more  than  two  inches  of  fat.  All  over  the 
abdomen  a  clear  resonant  note  could  be  determined,  no  traces  of 
fluctuation  could  be  detected,  the  cavity  of  the  pelvis  was  per- 
fectly normal,  her  functions  were  healthy,  and  nothing  distressed 
her  but  the  size  of  her  abdomen.  But  for  my  previous  experi- 
ence in  such  cases  I  might  have  hesitated  to  give  the  opinion  I 
did,  that  the  case  was  nothing  but  a  climacteric  accumulation  of 
fat  in  the  abdomen.  I  comforted  both  the  patient  and  her  doc- 
tor with  the  assurance  that  after  the  climacteric  period  was  over 
a  redistribution  of  fat  would  probably  occur,  that  it  would  be- 
come more  equalized  over  the  body  and  less  pronounced  in  the 
abdomen,  and  this  I  have  seen  occur  so  many  times  that  I  have 
little  doubt  that  in  the  case  I  am  describing  I  shall  find  in  about 
two  years  that  my  prognosis  will  be  verified. 

This  of  course  was  a  somewhat  extreme  case,  because  it  is 
m.uch  more  usual  to  find  a  general  increase  in  the  adipose  tissue 
of  the  body  than  that  it  should  be  deposited  in  the  abdomen  at 
the  expense  of  the  other  regions.  I  can,  however,  recall  to  mind 
a  sufficient  number  of  mistakes  which  I  have  made  in  such  cases 
as  this  to  be  able  to  give  a  warning  to  others  to  be  cautious  in 
expressing  an  opinion  concerning  the  existence  of  a  tumor 
merely  from  an  increase  in  the  size  of  the  abdomen  of  a  woman 
at  the  climacteric  period. 

Another  of  the  conditions  which  simulate  ovarian  tumors, 
and  one  about  which  we  must  be  more  cautious  than  any  other, 
14 


210  DISEASES   OF   THE   OVARIES. 

is  pregnancy.  I  have  already  said  that  during  the  whole  period 
of  gestation  menstruation  may  occur  with  normal  regularity 
and  in  normal  quantity,  and  also  that  a  rapidly  growing  ovarian 
cystoma  may  arrest  the  menstrual  flow.  It  has  been  my  experi- 
ence, as  it  must  have  been  the  experience  of  every  special  prac- 
titioner, to  have  patients  brought  to  me  as  suffering  from  tumor 
when  their  real  state  was  that  of  pregnancy,  and  I  need  hardly 
say  that  this  occurs  chiefly  in  unmarried  women.  I  have,  how- 
ever, had  it  occur  more  than  once  in  a  married  woman,  and  I 
can  call  to  mind  an  instance  of  this  of  a  somewhat  dramatic 
kind. 

A  lady  forty-two  years  of  age  who  had  been  married  twice 
and  whose  married  life  extended  over  eighteen  years  was 
brought  to  me  by  her  doctor  as  a  case  of  ovarian  tumor.  With 
very  great  difficulty  indeed  I  persuaded  him  that  it  was  a  case 
of  pregnancy,  and  that  she  must  be  within  a  few  days  of  her 
confinement.  My  opinion,  however,  was  entirely  disbelieved  by 
the  patient,  and  it  was  only  when  the  pains  of  labor  came  upon 
her  that  she  accepted  the  accuracy  of  my  opinion.  She  was 
confined  of  a  dead  child  and  her  labor  very  nearly  cost  her  her 
life.  Only  a  few  days  ago  a  hospital  patient  was  sent  to  me  as 
being  a  case  of  ovarian  tumor.  She  was  of  very  large  size,  the 
feet  and  legs  were  much  swollen,  nothing  could  be  felt  in  the 
pelvis,  and  she  had  seen  no  appearance  of  menstruation  for  six- 
teen months.  Yet  a  careful  stethoscopic  examination  revealed 
the  sounds  of  the  fetal  heart,  and  by  getting  my  hand  into  the 
vagina  I  found  the  cervix  normal,  though  very  high  up.  It 
turned  out  to  be  a  case  of  pregnancy  with  cardiac  dropsy. 

In  the  event  of  a  young  unmarried  woman  presenting  herself 
with  an  abdominal  tumor  the  utmost  caution  must  be  observed, 
for  there  is  no  limit  to  the  persistency  of  the  denial  such  patients 
will  make  as  to  their  condition.  Medical  experience  is  full  of 
illustrations  of  this,  and  I  have  heard  very  many  anecdotes  from 
my  professional  brethren  illustrating  it.  Some  of  their  patients 
even  went  so  far  as  to  deny  the  possibility  of  their  being  preg- 
nant when  labor  was  in  the  third  stage.  A  few  weeks  ago  a 
patient  came  to  the  hospital  to  consult  me  concerning  an  ab- 
dominal tumor.  It  was  manifestly  a  case  of  advanced  preg- 
nancy. Yet  when  it  was  delicately  suggested  what  the  possi- 
bility of  her  state  was,  she  indignantly  denied  it;  but  when  I 
proceeded  with  the  requisite  examination  I  found  not  only  that 
she  was  pregnant  but  that  the  recto-vaginal  septum  liad  been 
completely  destroyed  in  a  previous  labor.  No  amount  of  scep- 
ticism in  these  cases  will  therefore  be  too  great,  but  the  prac- 
titioner will  be  wise  who  keeps  that  scepticism  to  himself.     If 


OVARIAlsr  TUMOES,  CONDITIONS  WHICH  SIMULATE  THEM.     211 

the  tumor  is  of  small  size  and  the  patient  is  not  suffering,  only 
two  questions  need  be  asked — is  her  menstruation  arrested, 
and,  if  so,  was  it  regular  previous  to  its  recent  stoppage  ?  If 
these  two  questions  are  answered  in  the  affirmative,  I  would 
advise  that  an  examination  should  not  be  made  at  the  first  visit 
but  that  some  slight  placebo  be  given  and  the  patient  be  asked 
to  repeat  the  visit  at  an  interval  of  seven  or  eight  weeks;  and  at 
the  same  time  some  gentle  hint  may  be  dropped  that  the  case  is 
probably  one  of  a  nature  that  will  not  require  operation.  In  the 
majority  of  cases  I  find  this  is  quite  enough,  and  that  the  patients 
very  soon  realize  their  position  and  do  not  trouble  me  again.  If, 
however,  they  should  come  back,  upon  the  second  or  third  visit  I 
advise  that  an  investigation  should  be  made.  I  need  not  here 
describe  the  evidences  upon  which  we  base  a  diagnosis  of  preg- 
nancy, and  shall  allude  to  one  only  in  detail,  because  it  is  one 
but  little  known  as  yet,  and  it  is  a  sign  more  valuable  perhaps 
even  than  that  derived  from  auscultation,  in  that  it  can  always 
be  observed,  whereas  the  fetal  heart  cannot  always  be  heard.  I 
mean  the  rhythmical  contraction  of  the  uterus.  If  the  hands  be 
placed  on  the  abdomen  of  a  case  of  suspected  pregnancy  and  a 
fluctuating  tumor  be  felt,  that  tumor  will  become  quite  tense 
and  like  a  myoma  if  the  examination  be  prolonged  for  a  few 
minutes.  Then  again  it  will  become  flaccid  and  fluctuating,  and 
this  alternation  will  go  on  rhythmically  at  varying  intervals. 
Once  this  sign  has  been  felt  and  recognized,  I  think  it  will  be 
impossible  for  the  observer  ever  again  to  be  deceived  by  a  preg- 
nant uterus.  Let  me  again  impress  upon  every  one  the  neces- 
sitj''  of  caution  in  giving  an  opinion  to  the  effect  that  a  patient 
is  pregnant. 

A  most  disastrous  case  of  this  kind  occurred  some  years  ago 
in  my  practice,  where  a  young  and  very  attractive  girl,  who  suf- 
fered from  an  ovarian  tumor  which  I  subsequently  removed, 
was  examined  by  four  different  practitioners,  all  of  whom  were 
men  of  experience  and  two  of  whom  saw  the  patient  together  in 
consultation.  All  four  of  these  men  asserted,  I  am  told,  that 
they  heard  the  fetal  heart,  a  sign  which  is  regarded  as  conclu- 
sive of  the  existence  of  pregnancy.  The  girl  when  seen  by  me 
communicated  none  of  these  facts;  she  was  brought  tome  by 
her  parents  and  I  knew  nothing  of  her  previous  history.  I  had 
no  hesitation  at  all  in  pronouncing  it  to  be  a  case  of  ovarian 
tumor,  and  in  the  course  of  a  few  days  I  removed  it.  One  of  the 
practitioners  under  whose  care  she  had  been,  was  foolish  enough 
to  continue  his  statement  that  the  girl  had  been  pregnant  and 
that  my  statement  that  I  had  removed  an  ovarian  tumor  was  a 
falsehood.     For  this  extraordinary  conduct  he  was  very  properly 


212  DISEASES   OF   THE   OVAPwIES. 

called  to  account  by  the  parents  of  the  patient,  and  it  was  only 
by  his  tendering  a  most  ample  apology  that  he  was  saved  from 
an  action  for  damages.  Fortunately  for  me  it  happened  that 
the  operation  was  performed  in  the  presence  of  two  gentlemen 
who  knew  both  the  patient  and  the  practitioner,  so  that  it  was  a 
very  simple  matter  for  me  to  prove  the  accuracy  of  my  state- 
ment. 

The  interest  of  the  case  centres  upon  this:  How  was  it  that  all 
these  four  men  declared  that  they  heard  the  fetal  heart  ?  I  am 
bound  to  say  that  upon  this  point  I  can  offer  no  possible  expla- 
nation, unless  it  be  that  some  curious  intestinal  sound  of  a  rhyth- 
mical character  was  given  out  during  their  examinations.  But 
the  case  is  such  a  striking  one,  and  has,  I  believe,  been  so  disastrous 
to  the  practitioner  to  whom  I  have  alluded,  that  I  quote  it  as  a 
warning  to  every  one  to  exercise  the  utmost  caution  in  pronounc- 
ing an  unmarried  woman  pregnant.  Nevertheless,  when  such  a 
patient  presents  herself,  the  suspicion  of  pregnancy  must  be  ever 
present  in  the  mind,  for  it  is  by  far  the  most  likely  condition,  and 
it  must  only  be  by  repeated  examination  and  the  concurrent  tes- 
timony of  physical  signs  that  any  positive  opinion  should  be 
given.  Far  better  at  any  rate  to  defer  an  opinion  for  some  time 
than  to  run  into  such  a  mistake  as  that  I  have  instanced. 

One  other  caution  I  shall  give  in  connection  with  such  cases, 
and  that  is  never  under  any  circumstances  employ  a  sound 
where  there  is  a  possibility  of  pregnancy. 

Sometimes  pregnancy  may  coexist  with  an  ovarian  or  par- 
ovarian tumor,  and  this  might  of  course  happen  in  an  unmarried 
woman,  though  I  have  never  seen  such  a  case.  But  it  is  by  no 
means  infrequent  in  married  women,  and  then  the  diagnosis  is 
a  matter  of  very  great  difficulty.  We  are,  however,  removed 
from  the  risk  somewhat  by  the  fact  that  married  women  are 
much  more  likely  to  assume  they  are  pregnant  than  that  they 
are  not,  and  attention  will  be  drawn  to  their  condition  more  by 
unusual  size  than  by  any  other  feature,  and  they  have  no  in- 
ducement to  conceal  the  possibility  of  pregnancy. 

Here  I  may  mention  one  of  the  abnormal  conditions  of  preg- 
nancy which  every  now  and  then  leads  to  a  terrible  disaster  by 
being  mistaken  for  a  peritoneal  dropsy  or  an  ovarian  tumor.  In 
this  disease,  hydramnios,  we  have  of  course  an  arrest  of  men- 
struation for  some  montlis,  generally  four  or  five,  and  this  ought 
to  lead  to  a  suspicion  of  what  is  the  matter;  but  on  the  other 
hand,  being  one  of  the  diseases  of  the  primiparous  woman,  we 
liave  it  unfortunately  more  frequently,  or  at  least  quite  as  fre- 
quently, in  unmarried  women  as  in  married  women.  It  is  always 
associated  with  albuminuria,  and  very  often  in  its  course  we  have 


OVAMAlSr  TUMORS,  CONDITIONS  WHICH  SIMULATE  TIIEM.      213 

the  characteristic  convulsions  of  that  disease  when  it  is  asso- 
ciated with  pregnancy.  I  have  seen  eight  cases  of  hydramnios, 
and  I  am  very  pleased  to  be  able  to  say  that  I  have  not  been  led 
into  the  blunder  of  tapping  any  of  them.  Seven  out  of  these 
eight  cases  have  been  associated  with  twin  pregnancies,  and  this 
is  too  great  a  proportion  to  be  a  matter  of  accident.  They  have 
all  occurred  in  primiparous  women,  and  the  most  advanced  case 
had  reached  only  the  sixth  month  of  pregnancy.  The  disten- 
tion of  the  uterus  in  all  of  them  had  taken  place  with  amazing 
rapidity;  in  one  case  the  limit  of  time  was  probably  less  than  a 
fortnight.  I  would  therefore  advise  that  any  young  woman 
whose  abdomen  was  found  to  be  large,  and  in  whom  the  distention 
had  occurred  with  great  rapidity,  the  first  thing  to  be  examined 
should  be  the  urine,  and  if  this  be  found  to  be  albuminous,  let 
every  proceeding  be  taken  with  the  utmost  caution.  Of  course 
no  intestinal  note  of  resonance  will  be  found  save  at  the  usual 
seat  of  the  corona,  and  on  pelvic  examination  the  distention  of 
the  uterus  will  be  made  clear.  This  is  easily  determined  by  get- 
ting the  patient  into  the  erect  position  and  then  making  a  vaginal 
examination.  The  child  or  children  will  then  be  found  settling 
down  on  the  point  of  the  fiifeger,  and  can  easily  be  felt  through 
the  thinned  uterus.  A  slight  push  will  send  the  mass  floating 
up  toward  the  fundus,  whence  it  will  sink  in  a  few  seconds.  In 
this  way  I  have  readily  made  a  differential  diagnosis  between  a 
unilocular  ovarian  cyst  and  a  distended  uterus. 

The  diagnosis  will  then  be  complete,  and  the  treatment,  which 
is  to  empty  the  uterus  as  rapidly  as  possible,  to  administer 
chloroform  freely  in  the  event  of  convulsions,  and  to  give  such 
remedies  as  are  appropriate  for  puerperal  albuminuria,  may  at 
once  be  proceeded  with. 

I  have  known  three  practitioners,  all  men  of  ability  and  ex- 
tended experience,  who  have  been  unfortunate  enough  to  tap  a 
patient  suffering  from  this  disease,  and  who  were  immensely 
surprised  to  find  the  patients  miscarry  in  a  few  hours  and  die 
shortly  afterward.  When  conversing  with  these  men  I  found 
that  none  of  them  had  ever  heard  of  this  unusual  disease;  and 
yet,  from  my  own  experience,  I  can  hardly  regard  it  as  extreme- 
ly rare.  It  is,  however,  but  slightly  alluded  to  in  the  text-books 
upon  these  diseases. 

There  is  another  disease  in  which  fluid  is  collected  in  the  cav- 
ity of  the  uterus,  owing  to  occlusion  of  the  cervix,  and  to  which 
the  name  of  hydrometra  has  been  given.  This  condition  is  prob- 
ably very  rare;  I  have  only  seen  one  case.  It  is  rather  difficult 
to  understand  how  it  is  arrived  at,  more  particularly  in  such  a 
case  as  that  which  came  under  my  care,  in  which  the  patient 


214  DISEASES    OF   THE    OVAEIES. 

was  nineteen  years  of  age  and  had  menstruated  for  about  three 
years  in  the  normal  way.  Before  I  saw  her,  menstruation  had 
ceased  for  about  two  years,  and  her  abdomen  had  steadily  in- 
creased in  size.  The  physical  signs  were  all  those  of  a  parova- 
rian cyst,  and  I  did  not  examine  the  condition  of  the  pelvis  be- 
cause the  patient  was  a  virgin.  I  proceeded  to  operate  in  the 
ordinary  way,  and  found  there  was  no  appearance  of  the  layers 
of  peritoneum.  After  passing  through  what  was  clearly  a  thin 
layer  of  muscular  tissue,  I  opened  the  sac  and  removed  nine 
pints  of  clear  limpid  fluid.  The  inside  of  the  cyst  was  rugose, 
and  the  cyst  itself  rapidly  contracted  after  being  emptied. 
Passing  the  forefinger  of  my  right  hand  into  the  vagina  and 
having  my  left  forefinger  in  the  pelvis,  I  made  out  clearly  from 
the  relations  of  the  cervix  that  the  cyst  was  truly  the  cavity  of 
the  uterus,  I  fastened  in  a  drainage-tube,  and  kept  it  there  for 
about  three  weeks,  and  after  its  removal  the  wound  speedily 
healed.  The  patient  has  since  remained  in  perfect  health,  but 
has  never  menstruated.  I  doubt  very  much  if  I  should  have 
diagnosed  the  case  any  more  completely  if  I  had  examined  the 
pelvis  previous  to  the  operation,  and  the  mistake  I  made  fortu- 
nately turned  out  to  be  of  no  importance.  Had  I  been  able  to 
make  a  correct  diagnosis  of  the  case  it  would  have  been  an  easy 
matter  to  have  passed  a  drainage-tube  through  the  cervix  with- 
out performing  abdominal  section.  This  disease  is  only  alluded 
to  by  authors  as  a  possibility,  and  there  are  very  few  descrip- 
tions of  cases,  such  as  there  are  being  described  as  having  oc- 
curred in  old  women  after  the  climacteric.  There  is  one  excep- 
tion, given  by  M.  Richard  as  a  case  of  hydrosalpinx  in  which, 
when  he  applied  pressure,  he  was  able  to  force  the  fluid  into  the 
uterus  and  out  of  it.  His  diagnosis  may  of  course  be  correct, 
but  I  think  that  it  much  more  likely  was  a  case  of  hydrometra. 

The  retention  of  menstrual  fluid  within  the  cavity  of  the 
uterus  from  occlusion  of  the  cervix,  or  more  frequently  from 
atresia  of  the  vagina,  is  a  much  more  common  occurrence.  I 
have  seen  some  seven  or  eight  cases  of  it,  but  in  none  of  them 
did  there  seem  to  be  much  possibility  of  it  being  mistaken  for  an 
ovarian  tumor.  In  the  first  place  the  patient  is  nearly  always 
brought  under  notice  on  account  of  the  intense  menstrual  pain 
due  to  the  monthly  additions  to  the  contents  of  the  uterus.  The 
history  was  given  in  all  of  them  that  no  external  appearance  of 
menstruation  had  occurred,  and  these  two  circumstances  alone 
are  sufficient  to  suggest  the  true  nature  of  the  case.  Examina- 
tion of  the  patient  will  reveal  two  things  which  are  decisive. 
The  first  is  the  presence  of  a  tumor  of  comparatively  small  size, 
smooth,  ovoid,  central  in  position,  and  very  tender  to  the  touch; 


OVAEIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      215 

and,  secondly,  there  will  be  found  some  form  of  malformation  of 
the  genital  canal.  If  there  be  doubt,  an  examination  under  ether 
will  easily  reveal  the  fact  that  the  tumor  is  uterine.  Some  cases 
of  this  kind  are  described  as  occurring  in  women  who  have  men- 
struated normally  and  who  have  even  borne  children,  the  occlu- 
sion having  been  due  to  the  union  of  the  uterine  lips  or  of  the 
walls  of  the  vaginal  canal  after  some  injury  or  ulceration.  I 
have  not  seen  such  a  case,  but  the  symptoms  would  be  the  same, 
and  the  history  would  probably  give  a  significant  clue  to  the 
diagnosis. 

There  are  two  remaining  conditions  of  the  uterus  which  may 
require  to  be  differentiated  from  ovarian  tumors,  one  of  which 
is  much  more  common  than  the  diseases  I  have  just  spoken  of. 
They  are  fibro-cystic  tumors  and  myomata.  The  fibro-cystic 
tumor  of  the  uterus  is  an  extremely  rare  affection,  so  rare  that 
until  four  months  ago  I  had  never  seen  a  case,  and  in  that  case 
it  was  absolutely  impossible  to  distinguish  the  growth  from  a 
parovarian  cyst.  She  was  sent  to  me  by  Dr.  Leacroft,  of  Feck- 
enham,  and  was  seen  by  me  originally  about  five  years  ago,  when 
I  diagnosed  a  parovarian  cyst  and  advised  its  removal.  This  she 
declined,  and  in  the  interval  she  was  tapped  several  times  by  Dr. 
Leacroft,  at  each  tapping  the  tumor  being  apparently  emptied 
and  no  solid  matter  being  left.  She  had  never  been  pregnant, 
was  fifty-three  years  of  age  at  the  time  of  the  operation,  and 
had  menstruated  all  her  life  with  perfect  regularity,  until  the 
age  of  fifty.  After  the  climacteric  period  the  tumor  grew  with 
great  rapidity,  and  it  was  after  the  change  that  she  was  first 
tapped.  When  examined  the  uterus  appeared  to  be  quite  free 
from  the  tumor,  and  the  physical  signs  were  those  of  a  unilocular 
and  therefore  probably  parovarian  cyst.  At  the  operation  I  found 
the  tumor  to  be  densely  adherent  all  over  its  front  aspect,  and  I 
had  not  been  engaged  in  its  separation  long  before  I  recognized 
the  familiar  appearance  of  uterine  tissue.  It  was  quite  impossi- 
ble to  remove  the  whole  of  the  tumor,  which  consisted  entirely 
of  one  cyst,  and  I  left  about  one-sixth  of  it  in  the  pelvis,  cutting 
it  off  as  low  down  as  I  could  by  means  of  the  cautery  and  tying 
several  large  vessels.  Subsequent  examination  gave  conclusive 
evidence  that  the  walls  of  the  tumor  were  composed  of  uterine 
tissue.  The  operation  was  an  extremely  severe  one,  for  numerous 
coils  of  intestine  had  to  be  separated  from  the  posterior  wall  of 
the  tumor  and  both  ureters  were  laid  bare.  She  had  no  bad  symp- 
toms for  four  days,  but  upon  the  fifth  she  began  to  sink  and  died 
upon  the  seventh.  A  post-mortem  examination  was  made  by  Dr. 
Saundby,  who  found  that  the  space  occupying  the  lower  third  of 
the  abdomen  contained  a  considerable  quantity  of  bloody  fluid. 


216  DISEASES   OF  THE   OVARIES. 

on  removing  which  a  suppurating  area  was  discovered.  The 
lower  part  of  this  consisted  of  tlie  remains  of  the  uterine  mass. 
Dr.  Saundby  notes  that  a  loop  of  intestine  had  its  mesentery  en- 
tirely torn  away,  but  was  living  and  uninjured.  The  left  ureter 
was  compressed  by  old  inflammatory  adhesions,  and  the  left 
kidney  was  atrophied  and  cystic.  Death  in  this  case  might,  I 
think,  possibly  have  been  avoided  if  I  had  adopted  Dr.  Keith's 
plan  of  drainage.  It  is  very  likely  indeed  that  a  fatal  issue  would 
have  occurred  even  if  the  drainage-tube  had  been  used,  but  if  I 
had  another  such  case  I  should  certainly  use  it.  Had  I  operated 
when  I  first  saw  the  patient,  before  she  was  tapped,  I  think  it 
more  than  likely  she  would  have  recovered;  and  I  also  think  it 
might  have  been  better  to  have  clamped  the  cyst  outside  than  to 
have  dealt  with  it  by  the  intraperitoneal  method.  It  is  in  such 
exceptional  cases  that  the  clamp  may  be  of  service. 

The  growths  which  have  usually  been  described  as  fibro-cystic 
tumors  of  the  uterus  have  been  multi-cystic,  and  what  their  ori- 
gin is  I  really  cannot  say.  There  seems  to  be  no  tissue  in  the 
uterus  from  which  one  would  expect  cysts  to  grow,  yet  there  is 
no  doubt  they  are  produced  in  the  organ.  Their  diagnosis  as 
ovarian  tumors  would  be  very  much  the  same  as  the  diagnosis 
of  myomata,  with  the  addition  that  the  discovery  of  fluctuation 
would  lead  to  the  suspicion  of  cystic  disease.  I  am  under  the 
belief,  however,  that  without  experience  a  differential  diagnosis 
of  fibro-cystic  tumors  would  be  a  very  difficult  thing,  and  that  it 
is  possible  only  in  the  hands  of  a  surgeon  who  had  made  two  or 
three  previous  mistakes.  In  such  a  case  as  I  have  described  of 
a  unilocular  cystic  tumor  of  the  uterus  a  correct  diagnosis  was 
absolutely  impossible. 

Concerning  uterine  myoma  I  shall  only  speak  so  far  as  this 
disease  simulates  ovarian  dropsy,  for  with  the  many  other 
phases  of  it  I  am  not  at  present  concerned,  though  when  speak- 
ing of  ovariotomy  I  intend  dealing  more  fully  with  it.  There  is 
one  most  constant  clinical  feature  characterizing  myoma  which 
is  seldom  met  with  in  ovarian  cystoma,  which  alone  will  often 
decide  the  nature  of  the  case:  I  refer  to  menorrhagia.  I  have 
already  said  that  there  are  conditions  of  the  ovary  which  pro- 
duce intractable  uterine  hemorrhage,  but  this  is  quite  excep- 
tional. On  the  other  hand  we  see  many  cases  of  uterine  myoma 
in  which  hemorrhage  never  appears  as  a  leading  feature;  still, 
given  an  abdominal  or  pelvic  tumor,  constantly  recurring  men- 
orrhagia and  a  distinctly  anaemic  appearance  of  the  patient, 
the  surgeon  may  take  it  for  granted  that  the  chances  are  im- 
mensely in  favor  of  the  disease  being  a  uterine  myoma.  On  ex- 
amining the  abdomen  of  a  patient  suffering  from  the  disease  a 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      217 

variety  of  conditions  may  be  discovered.  Thus  there  may  be  a 
large  ovoid  smooth  tumor  occupying  a  perfectly  central  position 
and  which  may  give  rise  to  a  feeling  so  closely  resembling  fluc- 
tuation as  to  deceive  the  most  experienced  hands. 

Such  a  case  as  this  I  operated  upon  three  years  ago,  where  a 
very  distinguished  surgeon  had  previously  performed  dry  tap- 
ping, that  is  to  say,  he  plunged  a  trocar  deeply  into  the  tumor 
and  got  nothing  out,  the  result  of  this  experiment  being  that  the 
tumor  grew  with  increased  rapidity.  When  I  first  saw  her  I 
also  was  under  the  impression  that  the  tumor  was  ovarian  be- 
cause there  was  nothing  in  the  pelvis  to  contraindicate  that 
view,  and  the  tumor  was  uniformly  smooth  and  ovoid.  It  was 
only  after  repeated  examinations  that  I  began  to  entertain  a 
suspicion  that  the  tumor  was  really  uterine  and  was  probably 
one  of  the  variety  to  which  I  have  given  the  name  of  "  oedema- 
tous  myoma."  I  advised  the  removal  of  the  tumor,  and  when  I 
came  to  operate  I  found  that  this  suspicion  was  correct.  The 
tumor  grew  from  the  fundus  and  was  encapsulated  by  a  thick 
layer  of  uterine  tissue.  The  body  of  the  uterus  formed  an  ex- 
cellent pedicle  around  which  I  placed  a  clamp.  The  patient  re- 
covered perfectly  well  and  is  still  alive,  enjoys  excellent  health 
and  continues  her  occupation  of  monthly  nursing.  The  tumor 
on  removal  weighed  thirty-seven  pounds,  and  consisted  entirely 
of  uterine  muscle-cells  distended  into  a  meshwork  by  a  large 
quantity  of  serum  which  drained  away,  leaving  a  solid  mass 
of  only  about  twenty  pounds.  The  sexual  functions  of  this 
patient  are  wholly  unaltered. 

It  is  very  much  more  common  to  find  these  myomatous  tu- 
mors perfectly  solid,  so  that  they  give  no  sensation  of  fluctuation 
at  all,  and  instead  of  being  smooth  and  uniform  in  contour  they 
are  far  more  often  nodulated  into  eccentric  forms.  Sometimes 
their  position  is  not  at  all  central.  I  have  seen  a  large  myoma 
shaped  like  a  cocked  hat  running  up  altogether  on  the  right  side 
and  having  no  position  at  all  to  the  left  of  the  middle  line.  In 
such  a  case  there  can  hardly  be  room  for  doubt  in  the  diagnosis, 
for  we  never  see  ovarian  tumors  having  such  characters,  at 
least  none  such  has  ever  presented  itself  in  my  experience, 
although  sometimes  small  outlying  cysts  of  an  ovarian  tumor 
may  somewhat  resemble  through  the  skin  the  nodules  of  a 
uterine  myoma.  But  it  is  when  a  pelvic  examination  is  made 
that  little  room  is  left  for  doubt.  Nearly  always  the  tumor  may 
be  at  once  determined  as  having  a  most  intimate  relation  with 
the  uterus;  and  if  the  forefinger  of  one  hand  be  kept  firmly 
pressed  upon  the  cervix,  while  with  the  other  hand  the  tumor  is 
made  to  move  freely  from  above,  the  case  will  be  easily  and 


218  DISEASES   OF   THE    OVARIES. 

clearly  determined,  though  here  again  sometimes  an  ovarian 
tumor,  solid  and  with  a  very  short  pedicle,  may  very  closely  re- 
semble in  its  pelvic  conditions  those  of  a  uterine  myoma.  Fi- 
nally, the  sound  may  be  employed  to  assist  in  the  diagnosis.  In 
an  ovarian  tumor  the  uterus  is  rarely  elongated,  while  in  a  my- 
oma it  nearly  always  is;  but,  as  I  have  elsewhere  said,  with  in- 
creased experience  the  surgeon  will  find  the  sound  to  be  an  in- 
strument becoming  less  and  less  useful  to  him,  and  he  will  find 
the  cautions  I  have  already  given  regarding  its  employment  be- 
coming more  and  more  deserving  of  respect. 

Solid  uterine  tumors,  besides  the  absence  of  fluctuation,  often 
have  in  addition  two  vascular  signs  which  I  have  never  met 
with  in  ovarian  tumors;  namely,  an  aortic  impulse,  which  may 
be  seen  and  felt,  and  an  enlargement  of  the  uterine  arteries  to 
be  felt  in  the  vagina.  In  one  case  I  satisfied  myself  that  the 
tumor  was  uterine,  mainly  because  at  the  flexure  of  the  vagina 
on  one  side  I  felt  an  artery  as  large  as  the  radial.  There  is  also 
a  uterine  souffle  to  be  heard  in  most  of  the  growths,  and  it  is 
best  heard  in  the  vagina. 

If  the  tumor  be  found  to  be  solid  but  not  uterine,  yet  attached 
to  the  uterus  and  moving  it  to  an  extent  which  may  lead  to  the 
belief  that  it  is  ovarian,  then  we  have  a  choice  between  a  der- 
moid cyst,  a  fibroid  tumor  of  the  ovary,  cancer  of  the  ovary,  or 
a  pedunculated  myoma  of  the  uterus.  A  dermoid  cyst  is  rarely 
so  constituted  that  it  will  not  give  fluctuation  at  some  part  or 
other;  and  its  peculiar  nodulated  character,  with  here  and  there 
spots  of  bony  hardness,  will  often  betray  it.  Fibroid  tumors  of 
the  ovary  are  very  rare,  and  cancer  of  the  ovary  alone  occurs  in 
only  one  form,  the  fibroid,  which  is  of  extreme  rarity. 

Mere  dropsical  effusion  into  the  cavity  of  the  peritoneum  does 
not  usually  offer  any  difficulty  in  its  recognition,  but  every  now 
and  then  a  case  will  be  met  with  in  which,  from  exceptional 
causes,  some  difficulty  will  occur  in  recognizing  such  a  case. 
Thus  I  have  more  than  once  opened  an  abdomen  under  the  com- 
plete belief  that  I  should  find  an  ovarian  tumor,  but  have  in- 
stead found  only  masses  of  cancer  with  an  abundant  ascitic  ef- 
fusion. This  is  due  to  the  fact  that  in  such  a  case  the  intestines 
have  become  adherent  or  have  been  wedged  backward  by  a 
large  mass  of  fungus  in  the  omentum,  so  that  no  resonant 
note  could  be  obtained  in  front,  whilst  it  was  readily  given  in 
the  flanks.  In  such  a  case,  of  course,  the  mistake  is  of  no  great 
importance,  for  all  that  happens  is  that  the  patient  is  tapped 
by  an  exploratory  incision  instead  of  by  a  trocar,  and  there  is 
the  advantage  that  an  absolute  certainty  of  the  diagnosis  is 
arrived  at. 


OYARIAN^  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      219 

One  very  curious  case  came  under  my  notice  about  two  years 
ago  in  a  girl  aged  eighteen,  who  had  an  enormous  ascitic  effu- 
sion. When  she  was  admitted  under  my  care  at  the  Women's 
Hospital  there  was  no  difficulty  at  all  in  recognizing  the  condi- 
tion, so  that  I  tapped  her  for  it  more  than  once  and  was  abso- 
lutely certain  that  my  diagnosis  was  correct.  The  girl  appeared 
to  be  in  all  respects  save  that  of  the  dropsy  perfectly  healthy, 
and  no  kind  of  lesion  which  could  account  for  the  dropsy  could 
be  discovered.  In  order  to  clear  up  the  case  I  transferred  her  to 
the  care  of  a  friend  who  was  a  physician  attached  to  another  in- 
stitution. There  she  was  kept  under  observation  for  several 
months  without  any  additional  information  being  obtained,  save 
that  there  appeared  to  be  a  small  amount  of  effusion  in  both 
pleurae;  still  no  distinct  clue  could  be  obtained  of  the  cause  of 
her  singular  condition.  By  a  mischance  she  fell  into  the  hands 
of  another  practitioner,  who  unwisely  expressed  the  opinion  that 
it  was  undoubtedly  a  case  of  ovarian  disease,  and  he  proceeded 
to  treat  it  on  that  belief.  When  the  abdomen  was  opened,  how- 
ever, my  diagnosis  was  completely  confirmed,  but  unfortunately 
the  operator  did  not  take  advantage  of  the  opportunity  to  dis- 
cover the  cause  of  the  dropsy,  so  she  left  the  institution  in  which 
the  operation  was  performed  without  any  additional  light  being 
thrown  upon  the  case.  She  was  tapped  repeatedly  until  she 
died,  and  then  again  an  opportunity  was  lost  of  obtaining  infor- 
mation upon  one  of  the  most  remarkable  cases  which  has  ever 
been  under  my  care. 

Quite  recently  I  had  another  singular  experience  of  dropsy  of 
the  peritoneum  imitating,  still  more  closely,  cystic  disease.  I 
was  called  by  Mr.  Whitcombe,  the  superintendent  of  the  Bir- 
mingham Lunatic  Asylum,  to  see  a  girl  in  whom  the  abdomen 
had  increased  with  amazing  rapidity.  I  diagnosed  a  paro- 
varian cyst,  and  in  a  few  days  I  opened  the  abdomen  to  remove 
it.  I  found,  however,  that  it  was  not  a  cyst  of  the  broad  liga- 
ment, but  a  dropsical  distention  of  the  lesser  cavity  of  the  peri- 
toneum, due  to  occlusion  of  the  communicating  cavity  by  peri- 
tonitis. The  inflammation  was  general,  and  in  spite  of  drainage 
she  died  of  the  disease  in  a  few  days.  At  the  post-mortem  it 
was  found  that  the  whole  mischief  was  due  to  a  common  seam- 
stress' sewing  needle  lying  in  the  great  omentum  just  over  the 
foramen  of  Win  slow.  The  patient  had  probably  swallowed  it, 
and  from  the  stomach  it  had  passed  out  into  the  position  where 
it  was  found. 

Such  an  occurrence  is  of  course  of  the  most  unusual  kind,  but 
of  great  interest  as  showing  how  difficult  exact  diagnosis  is  in 
abdominal  diseases.     The  case  is  also  of  value  as  an  illustration 


220  DISEASES    OF    THE   OVARIES. 

of  the  advantage  of  an  exploratory  incision  over  tapping.  If  I 
had  tapped  in  this  case  at  the  usual  point,  I  should  have  gone 
straight  through  the  large  intestine  which  lay  immediately  in 
the  way,  displaced  by  the  distention  of  the  lesser  cavity  of  the 
peritoneum.  Death  must  have  resulted  from  such  a  mistake. 
My  third  and  fourth  cases  of  operations  for  peritoneal  hydatids 
are  of  sufficient  importance  to  be  given  in  full  detail. 

In  this  country  hydatid  disease  of  the  peritoneum  is  not  very 
common,  and  what  we  know  of  it  is  chiefly  derived  from  the  ex- 
perience of  practitioners  in  hot  countries,  more  particularly  in 
Australia,  where  this  form  of  parasitic  disease  seems  to  be  pecu- 
liarly rife.  I  have  seen  four  cases,  and  in  but  one  of  thein 
was  I  able  to  make  a  diagnosis  previous  to  operative  proceed- 
ings. They  all  presented  the  ordinary  appearance  of  abdom- 
inal tumors  of  a  cystic  character,  and  they  certainly  did  not 
yield  the  special  sign  upon  w^iich  so  much  reliance  is  placed  by 
some  authors — the  so-called  hydatid  fremitus.  I  understand, 
however,  that  our  great  English  authority  upon  this  disease.  Sir 
William  Jenner,  has  only  noticed  this  sign  once  in  his  large  ex- 
perience. The  invasion  of  the  peritoneum  by  these  parasites 
nearly  always  occurs  by  the  rupture  of  a  sac  in  the  liver,  from 
which  the  foreign  organisms  are  set  free  to  attach  themselves 
and  begin  another  phase  of  growth  in  the  peritoneum. 

The  first  case  which  I  saw  occurred  in  the  practice  of  Mr. 
Langley  Brown,  in  the  person  of  a  lady  w^ho  had  resided  in  Aus- 
tralia and  who  had  apparently  acquired  the  disease  there.  She 
had  several  distinct  and  separate  tumors  in  her  abdomen,  and  the 
pelvis  was  occupied  by  a  fluctuating  tumor  which  we  believed  to 
be  a  mass  of  hydatids.  A  complete  record  of  the  case  is  given  by 
Mr.  Brown  in  the  Birmingham  Medical  Review  for  July,  1876, 
to  which  I  am  indebted  for  the  following  resume.  There  was  a 
fluctuating  tumor  in  the  recto-uterine  cul-de-sac,  which  we  be- 
lieved to  be  a  mass  of  hydatids,  because  in  the  abdomen  was  an- 
other fluctuating  mass  attached  apparently  to  the  omentum.  I 
tapped  the  pelvis  and  drew  off  the  contents  of  the  mass  felt 
there,  and  from  this  operation  a  sharp  attack  of  peritonitis  fol- 
lowed, which  seemed  to  result  in  the  death  of  a  number  of  other 
colonies,  some  of  which  at  least  found  their  way  in  some  mys- 
terious fashion  through  the  walls  of  the  bladder  and  were  ex- 
truded by  the  urethra.  A  large  jarful  of  cysts  were  so  passed, 
much  more  than  the  bladder  could  have  contained,  and  there 
was  no  kidney  tumor  to  account  for  them;  nor  is  there  reason 
to  believe  they  grew  in  the  bladder.  The  explanation  may  be 
that  they  were  really  extra-peritoneal,  or  that  the  pelvic  mass 
may  have  been  a  ureter.     The  scolices  found  in  them  were  pro- 


OVAEIAN  TUMOES,  CONDITIOj^S  WHICH  SIMULATE  THEM.      221 

nounced  by  Dr.  Cobbold  to  be  those  of  echinococcus  liominis,  and 
the  patient  made  a  perfect  recovery. 

The  second  case  occurred  in  the  person  of  a  hospital  patient 
who  had  spent  all  her  life  in  the  neighborhood  of  Birmingham, 
and  who  had  nothing  in  her  history  or  in  her  physical  signs  to 
lead  me  to  believe  the  dii|ease  from  wliich  she  suffered  was  other 
than  a  cystic  tumor  of  the  ovary.  Even  after  I  had  opened  the 
abdomen  I  found  the  organs  so  matted  together  with  cysts  of 
varying  size,  having  all  the  appearances  of  ovarian  cysts  so  in- 
timately associated  with  all  the  structures,  that  it  was  some 
time  before  I  recognized  what  the  extraordinary  condition  really 
was.  I  removed  a  few  of  the  cysts,  and  a  microscopical  exami- 
nation completely  revealed  the  nature  of  the  case.  The  tenta- 
tive operation  had  a  fatal  result,  and  upon  post-mortem  exami- 
nation the  hydatids  were  found  to  occupy  the  whole  abdominal 
cavity— to  have  insinuated  themselves  into  the  muscles  of  the 
walls  and  into  various  organs  besides  the  liver,  so  that  the 
operation  could  not  have  been  completed  by  any  possibility. 

R.  P.,  aged  eighteen,  was  seen  by  me  in  consultation  with 
Dr.  Hickinbotham  and  Mr.  Pugh,  of  Ashted,  on  December  23, 
1881,  on  account  of  a  pelvic  tumor,  with  which  "were  associated 
very  severe  symptoms.  There  was  a  high  temperature,  and  the 
pulse  was  extremely  rapid.  The  patient  was  constantly  sick 
and  presented  all  the  appearance  of  being  extremely  ill.  In  fact 
Mr.  Pugh  had  called  in  Dr.  Hickinbotham  under  the  impression 
that  she  was  dying,  and  they  asked  me  to  see  her  on  account  of 
a  large  mass  in  the  pelvis,  which  they  regarded  as  an  abscess. 
When  I  saw  the  patient  I  concurred  in  their  view,  and  the  pa- 
tient was  sent  at  once  to  the  Hospital  for  Women  for  the  pur- 
pose of  an  abdominal  section.  This  I  performed  next  morning, 
in  the  presence  of  Dr.  Hickinbotham,  Dr.  Savage,  and  Mr.  Pugh, 
and  assisted  by  Mr.  J.  Raffles  Harmar.  On  opening  the  perito- 
neal cavity  I  found  that  all  the  structures  were  matted  together, 
and  that  it  was  extremely  difficult  to  identify  any  of  them.  The 
adhesions  were  those  of  recent  peritonitis  and  also  the  peculiar 
agglutination  caused  by  the  presence  of  hydatids  in  the  perito- 
neum. Deep  down  in  the  pelvis,  and  attached  to  the  back  of  the 
right  broad  ligament,  I  found  a  bunch  of  hydatid  cysts,  some  of 
which  I  removed  and  others  of  which  I  ruptured.  On  the  left 
side  was  a  much  larger  mass,  which  I  could  not  touch  on  account 
of  the  dense  adhesion  of  layers  of  intestines.  I  therefore  inserted 
a  glass  drainage-tube  and  closed  the  wound  over  it.  The  tube 
was  removed  on  the  fourth  day,  but  the  pulse  and  temperature 
did  not  fall  perceptibly  till  the  eighth  day.  The  sickness,  how- 
ever, ceased  almost  immediately  after  the  operation,  and  the 


222  DISEASES   OF  THE   OVARIES. 

patient  complained  of  no  pain  after  the  third  day.  On  the  four- 
teenth day  the  mass  on  the  left  side  had  diminished  to  less  than 
one-half  of  the  size  which  it  had  at  the  time  of  the  operation. 
She  left  the  hospital  on  the  twenty-fourth  day,  at  which  time 
the  pelvic  mass  had  almost  disappeared,  and  the  patient's  symp- 
toms were  all  gone.  She  had  gained  ilnmensely  in  health  and 
strength,  and  Mr.  Pugh  reports  that  she  is  now  quite  well  and 
going  about. 

There  are  two  points  of  note  in  this  case,  in  that  it  illustrates 
that  remarkable  fact,  of  which  I  have  published  many  illustra- 
tions, that  a  judiciously  performed,  yet  incomplete,  operation 
may  often  effect  a  complete  cure,  and  that  the  chief  difficulty  in 
abdominal  surgery  is  to  know  when  to  stop.  The  latter  lesson 
is  to  be  learned  only  in  the  school  of  painful  experience. 

The  fourth  case  occurred  in  a  woman  aged  twenty-six,  placed 
under  my  care  by  Dr.  Blackwood,  of  Wednesbury,  in  whom  a 
pelvic  tumor  had  been  growing  for  two  years.  Until  last  Christ- 
mas she  had  suffered  very  little  inconvenience  from  it,  but  at 
that  time  it  became  very  painful,  increased  greatly  in  size,  and 
obliged  her  to  remain  in  bed. 

I  saw  her  on  January  16, 1882,  with  Dr.  Blackwood,  and  found 
a  large  fluctuating  tumor  rising  almost  as  high  as  the  umbilicus, 
quite  fixed  and  extremely  tender.  The  patient  had  a  high  tem- 
perature and  rapid  pulse,  and  was  quite  unable  to  straighten 
herself  in  bed.  I  was  of  opinion  that  she  was  suffering  from  a 
large  abscess,  though  I  could  not  make  out  much  in  the  pelvis. 
I  admitted  her  to  the  hospital  for  the  purpose  of  performing  ab- 
dominal section,  and  this  I  did  on  January  23d. 

I  found  the  tumor  to  be  a  large  sac  full  of  hydatids.  I  emptied 
it  and  fastened  in  a  large  glass  drainage-tube,  and  the  patient  is 
already  nearly  quite  recovered.  The  cyst  is  quite  small,  and  the 
secretion  from  it  is  perfectly  healthy  pus.  All  her  symptoms 
have  disappeared. 

I  do  not  know  what  the  relations  of  the  cyst  were,  more  than 
it  was  in  the  peritoneum  and  had  intestines  adherent  to  it.  In 
this  case,  as  in  the  other,  tapping  would  have  been  quite  use- 
less. 

At  the  present  time  (July  15,  1882)  these  cases  remain  per- 
fectly well. 

An  equally  rare  condition,  which  it  is  perfectly  impossible  to 
diagnose  previous  to  operation,  is  one  of  which  I  have  been 
able  to  find  only  one  case  recorded  besides  the  case  which  has 
occurred  in  my  own  experience.  In  the  American  Journal  of 
Medical  Science  for  October,  1852,  Dr.  Buckner  relates  a  case 
which  he  diagnosed  as  an  ovarian  tumor,  and  upon  which  he 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  THEM.      223 

decided  to  operate  under  that  belief.  When  he  came  to  operate, 
however,  the  tumor  was  found  to  be  not  ovarian  at  all,  but  a 
cyst  situated  in  the  mesentery  between  the  layers  of  the  peri- 
toneum and  surrounded  by  small  intestines.  He  proceeded  with 
the  operation  and  dissected  the  tumor  out,  dividing  in  his  pro- 
ceeding the  superior  and  middle  mesenteric  arteries,  which  he 
had  to  tie.  The  patient  recovered,  and,  in  spite  of  the  great  sep- 
aration of  the  mesentery  from  the  intestine,  no  apparent  bad 
consequences  of  any  kind  ensued. 

My  own  case  occurred  in  February,  1878,  and  was  of  a  pre- 
cisely similar  nature.  My  diagnosis  before  the  operation  was 
that  of  a  parovarian  cyst,  and  if  I  had  tapped  her  instead  of 
opening  the  abdomen  I  should  in  all  probability  have  killed  her, 
for  just  at  the  point  of  election  for  tapping  I  -found,  as  soon  as  I 
had  opened  the  peritoneum,  a  loop  of  intestine  running  at  right 
angles  to  my  incision.  I  did  not  do  as  Dr.  Buckner  did — dissect 
out  the  cyst.;  I  contented  myself  with  the  much  less  severe  oper- 
ation of  tapping  it  and  fastening  in  a  drainage-tube.  In  this  way 
I  completely  cured  my  patient  and  she  remains  to  this  day  per- 
fectly well. 

At  first  sight  it  would  hardly  be  thought  likely  that  tumors 
of  the  liver,  gall-bladder,  kidney,  and  spleen  would  often  be  mis- 
taken for  ovarian  tumors,  but  I  have  had  a  large  number  of 
cases  of  these  conditions  sent  to  me  as  ovarian  tumors,  and  I 
have  on  several  occasions  opened  the  abdomen  under  the  im- 
pression that  I  was  about  to  remove  an  ovarian  tumor  and  found 
the  case  to  be  one  of  tumor  of  the  kidney.  On  the  other  hand  I 
have  several  times  removed  ovarian  tumors  which  in  the  earlier 
stage  of  their  existence  have  been  diagnosed  as  floating  kidneys. 
In  fact  there  is  one  physician  of  my  acquaintance  who  seems  to 
have  a  wonderful  power  of  finding  cases  of  this  abnormality,  and 
I  think  that  no  less  than  three  of  my  ovariotomies  have  been 
diagnosed  by  him  as  cases  of  floating  kidney  before  they  came 
under  my  care.  I  cannot  do  better  perhaps  than  quote  what  is 
said  concerning  this  by  Mr.  Spencer  Wells  in  his  lectures  to  the 
College  of  Surgeons  : 

"  I  do  not  think  there  is  a  specimen  here,  I  doubt  whether 
there  is  in  the  Museum,  of  what  is  called  '  movable  kidney.'  I 
believe  there  have  been  only  one  or  two  such  specimens  shown 
after  death  at  the  Pathological  Society,  but  I  have  occasionally 
seen  tumors  in  the  abdomen  which  appeared,  as  far  as  one  could 
tell,  to  be  instances  of  movable  kidneys,  either  enlarged  or  of 
their  natural  size.  One  case  is  such  a  remarkable  one  that  I  will 
detain  you  a  moment  to  tell  you  about  it.  A  lady  came  to  me 
believing  she  had,  or  having  been  told  she  had,  a  movable  right 


224  DISEASES   OF   THE   OVARIES. 

kidney.  I  saw  her  with  Dr.  Wilson  Fox,  and  we  both  agreed 
that  was  the  nature  of  the  disease.  For  some  years  it  went  on, 
and  I  saw  her  occasionally  under  the  impression  that  she  was 
suffering  from  a  movable  kidney.  Then  she  became  pregnant, 
and  pregnancy  went  on  to  its  natural  termination  and  a  healthy 
child  was  born.  Soon  afterward  she  began  to  suffer  from  an 
ovarian  cyst  on  the  left  side,  the  movable  kidney  still  being  on 
the  right  side;  and  the  ovarian  cyst  increased  so  much  that  it 
was  decided  I  should  perform  ovariotomy,  which  I  did.  I  said 
at  the  time,  '  I  will  see  what  that  movable  kidney  is  now; '  and 
after  I  had  removed  the  ovarian  cyst  on  the  left  side  I  felt  what 
the  supposed  kidney  was  and  took  it  out,  and  then  I  found  it 
was  the  right  ovary,  but  it  was  attached  by  a  pedicle  fully  a  foot 
long.  It  had  been  held  up  under  the  right  false  ribs  by  the 
merest  little  film  of  adhesion.  Quite  a  small  patch  of  adhesion 
kept  this  right  ovary,  which  was  about  the  size  of  my  fist  and 
very  much  the  shape  of  a  kidney,  just  in  the  position  of  a  mov- 
able kidney.  The  patient  recovered  and  remained  in  good 
health." 

Tumors  of  the  kidney  sometimes  extend  so  low  down  that 
they  can  be  felt  in  the  pelvis,  and  they  are  often  so  movable, 
especially  from  side  to  side,  that  it  is  quite  impossible  to  say 
whether  they  are  or  are  not  ovarian  tumors.  One  such  case  was 
placed  under  my  care  by  my  colleague,  Dr.  Hickinbotham,  and  I 
opened  the  abdomen  perfectly  believing  that  I  was  about  to  deal 
with  an  ovarian  cyst.  I  found,  however,  that  it  was  a  large  cyst 
of  the  kidney  which  I  could  not  remove,  but  I  dealt  with  it  by 
opening  it,  emptying  it,  and  stitching  the  wound  in  its  wall  to  the 
wound  in  the  wall  of  the  abdomen  and  fastening  in  a  wide  glass 
drainage-tube.  The  cyst  suppurated  freely.  The  patient  was 
completely  cured  in  about  two  months. 

Now  that  abdominal  surgery  has  made  the  great  advances  re- 
corded in  the  last  three  or  four  years,  I  have  little  doubt  that  tu- 
mors of  the  kidney  will  by  and  by  be  dealt  with  as  successfully 
as  uterine  tumors  certainly,  and  perhaps  even  as  successfully  as 
ovarian  tumors.  The  deliberate  removal  of  the  kidney  by  Simon, 
of  Heidelberg,  which  was  successful,  and  the  removal  of  a  large 
cystic  kidney  by  Dr.  Campbell,  of  Dundee,  in  mistake  for  an  ova- 
rian tumor,  with  an  equally  fortunate  result,  will  probably  in 
time  lead  the  way  to  further  triumphs.  As  far  as  my  own  ex- 
perience goes  I  have  only  once  removed  an  enlarged  kidney,  and 
in  that  case  the  success  was  complete,  and  I  am  glad  to  say  that 
all  my  patients  have  recovered  from  the  incomplete  operations. 

Enlargements  of  the  spleen  have  been  mistaken  for  ovarian 
tumors,  but  this  is  hardly  so  pardonable  a  mistake.     The  posi- 


OVARIAN  TUMORS,  CONDITIONS  WHICH  SIMULATE  TIIEM.     225 

tion  of  the  spleen  when  enlarged,  the  history  of  its  growth,  and 
the  appearance  of  the  patient  in  most  cases  are  sufficient,  I 
think,  to  prevent  the  mistake  being  made.  Besides  this  there  is 
one  perfectly  decisive  sign  in  the  case  of  a  spleen  which  ought 
always  be  looked  for  and  will  always  be  found.  It  is  that  on  the 
right  side  of  the  tumor  may  be  felt  a  sharp  edge  under  which 
the  fingers  may  be  passed,  especially  if  the  patient  is  asleep,  and 
the  tumor  may  then  be  tilted  over  on  its  own  axis  upward  and 
toward  the  left.  This  edge,  moreover,  has  a  peculiar  arrange- 
ment of  festoons  along  its  margin,  the  notches  of  which  are 
from  three  to  five  inches  apart,  and  when  these  notches  are  dis- 
covered there  can  be  no  doubt  whatever  of  the  tumor  being  the 
spleen;  and  finally,  if  there  should  still  be  doubt  a  microscopical 
examination  of  the  blood  will  usually  give  abundant  proof  of 
diseased  spleen  by  the  excess  of  white  blood  corpuscles.  I  have 
opened  the  abdomen  three  times  in  the  hope  of  being  able  to  re- 
move a  splenic  tumor,  but  have  never  yet  been  able  to  accom- 
plish it.  These  three  patients  recovered  from  the  operation  and 
two  of  them  have  since  been  completely  cured.  Whether  that 
was  a  result  of  the  exploratory  incision  or  not  I  cannot  say,  but 
the  patients  were  subjected  to  no  other  treatment  for  months 
after  the  operation  than  they  had  experienced  for  some  months 
before  it.  The  third  case  is  yet  more  remarkable  and  is  still  under 
observation.  I  opened  the  abdomen  and  failed  to  remove  the 
spleen.  Three  weeks  afterward  a  large  abscess  formed  in  the 
spleen;  this  I  laid  open,  without  any  Lisfcerian  precautions,  and 
inserted  a  drainage-tube.  The  amount  of  pus  in  this  huge  ab- 
scess was  two  and  a  half  pints.  The  patient  is  slowly  recovering 
and  the  spleen  is  shrinking.  I  know  of  two  cases  of  removal  of 
the  spleen  in  this  neighborhood  both  of  which  proved  fatal;  in 
one  of  them  the  organ  was  removed  in  mistake  for  an  ovarian 
tumor. 

Perhaps  the  least  likely  of  all  the  conditions  to  which  I  have 
alluded  as  being  mistaken  for  an  ovarian  tumor  would  be  a  tu- 
mor of  the  liver,  yet  I  have  to  confess  that  in  one  instance  I 
committed  this  curious  error.  The  patient  was  sent  to  me  from 
Leicester  with  all  the  signs  of  a  large  cystic  tumor  of  the  ovary, 
but  when  I  opened  the  abdomen  I  found  a  large  collection  of 
ascitic  fluid,  due  to  a  huge  mass  of  soft  cancer  which  grew  by  a 
narrow  pedicle  from  the  liver.  The  abdomen  was  closed  and  the 
patient  was  enabled  to  return  home,  where  she  died  shortly  after- 
ward. I  believe  it  would  be  quite  possible  in  some  extreme  cases 
to  mistake  a  hydatid  tumor  of  the  liver  for  an  ovarian  tumor.  A 
year  ago  I  operated  upon  a  lady  in  whom  the  diagnosis  of  hyda- 
tids of  the  liver  was  made  by  Sir  William  Jenner,  and  I  think  one 
15 


226  DISEASES   OF   THE   OVARIES. 

less  experienced  than  that  distinguished  physician  might  have 
taken  the  tumor  for  an  ovarian  cyst.  It  occupied  the  whole  of 
the  abdomen  and  distended  it  enormously,  and  the  edge  of  the 
tumor  could  be  felt  in  the  pelvis.  I  opened  the  abdomen  and 
then  opened  the  liver,  emptied  between  two  and  three  gallons  of 
hydatids,  fastened  the  two  wounds  together  by  continuous  suture, 
secured  a  drainage-tube  well  into  the  cavity,  and  succeeded  in 
curing  the  patient.  The  case  is  published  in  the  volume  of  the 
"  Transactions  of  the  Royal  Medical  and  Chirurgical  Society  "  for 
1880,  and  since  that  time  I  have  operated  upon  eight  other  cases 
of  a  similar  character  with  perfect  success  in  all.  I  have  also 
opened  the  distended  gall-bladder  and  removed  gall-stones  in 
three  cases  by  a  similar  operation,  and  have  in  these  cases  also 
had  perfectly  successful  results,  so  that  we  have  a  prospect  of  a 
remarkable  extension  of  abdominal  surgery  in  unexpected  direc- 
tions. 

There  is  one  condition  of  the  ovary  concerning  which  a  very 
great  deal  of  discussion  has  taken  place,  and  upon  which  I  am 
yet  by  no  means  clear  that  a  satisfactory  conclusion  has  been 
arrived  at.  I  refer  to  the  displacement  which  has  been  described 
as  ovarian  pregnancy.  It  is  a  question  which  has  a  much  greater 
interest  from  a  pathological  than  from  a  clinical  point  of  view, 
because  even  if  there  be  such  a  condition  as  ovarian  pregnancy 
I  do  not  see  that  the  treatment  required  for  it  would  be  in  any 
way  different  from  that  required  in  Fallopian  pregnancy,  which 
I  have  fully  described  in  another  chapter.  Until  the  appearance 
of  Velpeau's  article  in  the  "  Dictionnaire  de  Medecine,"  most  of 
the  cases  of  extra-uterine  pregnancy  seem  to  have  been  regarded 
as  instances  of  the  actual  impregnation  and  development  of  the 
ovum  within  the  structure  of  the  ovary  itself,  and  it  is  very  evi- 
dent from  the  description  of  a  number  of  cases  of  dermoid  tumor 
of  the  ovary  that  these  singular  structures  were  also  regarded 
as  having  this  origin.  In  fact,  I  think  I  may  say  that  between 
the  incomplete  development  of  a  foetus  in  the  dermoid  cyst  to  its 
complete  development  in  the  extra-uterine  pregnancy,  there 
does  not  seem  to  have  been  any  clear  distinction  until  about  1850. 
The  assertion,  therefore,  that  ovarian  pregnancy  does  really 
occur  is  made  by  the  great  majority  of  authors  without  any 
really  critical  examination  of  the  facts  of  the  case, 

I  have  spent  a  great  deal  of  time  in  the  investigation  of  the 
literature  of  the  subject,  and  I  am  bound  to  say  that  I  am  scep- 
tical as  to  the  reality  of  the  descriptions  of  any  of  the  instances 
which  have  yet  been  given  of  this  phenomenon.  Spiegelberg, 
according  to  Schmiet,  has  established  the  authenticity  of  nine 
cases  and  has  added  ten  more  ;  but  Dr.  Parry  contents  himself 


OVARIAN  TUMOES,  CONDITIONS  WHICH  SIMULATE  THEM.      227 

with  merely  saying  that  the  weight  of  authority  is  in  favor  of 
the  possibility  of  ovarian  pregnancy.  Further  than  this  I  cer- 
tainly am  not  inclined  to  go,  for  if  we  consider  for  a  moment 
the  chain  of  circumstances  which  alone  could  lead  to  such  an  inci- 
dent, we  can  readily  understand,  in  the  first  place,  how  extreme- 
ly rare  its  occurrence  must  be  ;  and,  in  the  second  place,  how  diffi- 
cult it  is  to  prove  what  is  absolutely  necessary — that  the  ovum 
was  developed  within  the  follicle  which  it  had  never  left.  We 
must  imagine,  in  the  first  place,  that  the  spermatozoa  had  pene- 
trated the  whole  length  of  the  Fallopian  tube,  a  circumstance 
which  must  be  of  extreme  rarity  if  the  views  of  the  physiology 
of  the  oviduct  which  I  have  advanced  be  correct.  We  must 
then  further  see  that  this  incident  must  have  occurred  at  the 
time  when  the  pavilion  has  embraced  the  ovary,  and  the  em- 
brace must  have  occurred  at  the  spot  where  the  follicle  was 
about  to  rupture.  After  all  this  the  most  extraordinary  inci- 
dents of  the  process  must  occur  :  the  ovum,  instead  of  leaving 
the  follicle  when  the  rupture  takes  place,  must  remain  within 
it ;  the  spermatozoa  must  enter  through  the  rupture  ;  the  rupture 
must  then  heal ;  the  ovum  must  become  reattached  to  the  epithe- 
lial lining  of  the  follicle  ;  the  rupture  heals,  and  then  the  develop- 
ment of  the  ovum  must  take  place  within  the  walls  of  its  origi- 
nal home.  Supposing  the  whole  train  of  these  extraordinary 
circumstances  to  have  occurred,  it  would  not  be  impossible  to 
imagine  that  the  follicle  would  distend  as  it  does  in  the  case  of 
cystic  growth,  and  that  we  should  have  a  case  of  true  ovarian 
pregnancy. 

During  the  progress  and  development,  and  in  many  of  the 
troublesome  accidents  through  which  all  cases  of  extra-uterine 
pregnancy  must  pass,  there  would  inevitably  occur  such  adhe- 
sions and  displacements  as  would  make  it  most  difficult  to  prove 
that  the  actual  seat  of  the  foetus  was  within  the  tissue  of  the 
ovary.  Among  many  other  conditions  which  would  have  to  be 
f ulffiled  the  following  are  some  of  the  most  important.  In  the 
first  place,  of  course  it  would  be  quite  impossible  to  admit  any 
case  as  one  of  ovarian  pregnancy  in  which  a  most  careful  post- 
mortem examination  had  not  been  made,  by  a  thoroughly  com- 
petent observer.  Then  we  should  have  to  find  that  the  uterus 
and  both  tubes  were  absolutely  intact ;  that  one  ovary  was  pres- 
ent and  that  the  other  could  not  be  accounted  for  save  by  its 
existence  as  the  cyst  of  the  pregnancy  ;  and  in  the  cyst  wall  of 
such  a  case  there  would  have  to  be  found  microscopic  evidence 
of  ovarian  tissue.  In  several  cases  of  tubal  pregnancy  which  I 
have  dissected  it  was  a  matter  of  the  utmost  difficulty  to  find 
the  corresponding  ovary,  even  when  it  was  perfectly  clear  that 


228  DISEASES   OF   THE   OVARIES. 

the  seat  of  the  pregnancy  was  one  of  the  Fallopian  tubes.  In 
one  of  my  dissections  I  could  not  find  the  ovary,  and  yet  that 
case  was,  with  perfect  certainty,  one  of  tubal  pregnancy.  In 
Spiegelberg's  paper  there  is  only  one  case  cited  to  which  these 
tests  apply  with  any  degree  of  satisfaction,  and  therefore  I  give 
its  details  in  full. 

An  abdominal  section  was  performed  under  circumstances  of 
great  difficulty,  and  after  peritonitis  had  been  some  time  in  ex- 
istence the  sac  had  become  closely  adherent  to  the  great  intes- 
tine and  to  the  right  wall  of  the  pelvis.  On  both  sides  the  tubes 
were  normally  distributed,  but  the  left  one,  after  a  course  of 
7  ctm.,  disappeared  in  the  walls  of  its  broad  ligament.  The  right 
tube  extended  10  ctm.  along  the  upper  edge  of  the  thickened, 
broad  ligament  toward  a  sac  which  was  united  by  the  ligamen- 
tum  ovarii  to  the  ala  vespertilionis  of  the  uterus;  it  had  a  di- 
ameter of  10  ctm.  and  was  in  a  collapsed  condition.  After  the 
tube  had  reached  the  sac  it  could  be  traced  along  its  surface  for 
a  distance  of  22  ctm.  and  was  permeable  for  a  distance  of  12 
ctm.,  and  in  the  remaining  10  ctm,  of  its  length  it  disappeared 
as  a  narrow,  smooth  band  on  the  outer  surface  of  the  sac.  There 
v/as  in  this  neighborhood  a  small  dermoid  cyst  in  the  wall  of  the 
cac  without  any  distinct  boundary.  The  sac  itself  had  two 
layers,  the  outer  of  which  "was  thick  and  firm,  and  the  inner 
one  fine  and  delicate,  these  two  being  capable  of  easy  separa- 
tion. The  inner  layer  was  clearly  the  chorion,  for  over  its 
greatest  part  it  had  the  structure  of  placenta,  which  was  thick- 
est at  the  bottom  of  the  sac  and  thin  at  the  upper  part. 

Spiegelberg  therefore  concludes  that  the  right  ovary  was  the 
bag  containing  the  child.  He  could  find  no  ovary  on  the  right 
side,  but  he  found  distinct  ovarian  elements  in  the  outer  wall  of 
the  sac.  It  must  here  be  pointed  out  that,  in  the  first  place,  the 
post-mortem  examination  is  admitted  to  have  been  not  very  effi- 
ciently performed,  and  the  description  given  of  the  tube  makes 
it,  I  think,  quite  as  likely  that  it  was  a  case  of  pregnancy  in  the 
broad  ligament  which  resulted  in  the  rupture  of  the  tube  on  its 
lower  aspect — that  being  the  most  common  variety  of  the  tubal 
pregnancies  which  are  not  fatal  in  their  early  rupture — as  that  it 
was  a  case  of  ovarian  pregnancy.  The  fact  that  there  was  pres- 
ent an  ovarian  tumor  is  proved  by  the  existence  of  a  dermoid 
cyst.  This  would  account  for  the  somewhat  wide  distribution 
of  ovarian  elements  in  the  wall  of  the  sac,  and  as  Spiegelberg 
does  not  claim  to  have  found  ovarian  elements  all  over  the  vv^all 
of  the  sac,  I  think  we  may  be  quite  justified  in  being  somewhat 
sceptical  even  about  this  case;  though  I  frankly  admit  that  the 
eminence  of  the  observer  and  the  manifest  care  with  which  all 


OVAKIAiSr  TUMORS,  CONDITIONS  WUICH  SIMULATE  THEM.      229 

his  records  are  given  make  it  quite  possible  that  his  conclusions 
are  correct.  Since  this  was  written,  I  regret  to  say,  Prof.  Spie- 
gelberg  has  passed  over  to  the  majority. 

In  a  paper  published  by  M.  Puech  upon  this  subject  he  de- 
scribes a  case  in  which  the  left  Fallopian  tube,  like  the  right, 
was  fixed  behind  the  ovary  by  adhesion,  but  had  remained  per- 
meable. Its  pavilion  was  closed  in  great  measure,  but  not  com- 
pletely, and  admitted  a  probe.  The  left  ovary  measured  -46  mms. 
long,  26  mms.  broad,  and  18  mms.  thick.  It  contained  Graafian 
follicles  of  various  degrees  of  development,  the  largest  being  8 
mms.  in  diameter.  On  its  outer  extremity  was  a  rounded  body 
about  the  size  of  a  large  cherry,  its  largest  diameter  being  20 
mms.,  while  its  smallest  was  12  mms.  Its  envelope  was  trans- 
parent and  furnished  with  well-marked  reticulated  vessels.  At 
one  spot  a  deep  violet  coloration  was  seen  over  a  space  about 
the  size  of  a  lentil,  and  around  this  the  envelope  was  thickened. 
Over  most  of  the  rest  of  the  surface  a  yellowish  substance  could 
be  seen  through  the  translucent  envelope.  On  opening  the  cyst 
with  scissors  a  prominence  with  a  villous  surface  was  found 
attached  at  the  area  of  coloration,  while  over  the  rest  of  the  sur- 
face a  layer  ^  mm.  thick  could  be  easily  separated  from  the  cyst 
wall.  The  villous  prominence  was  furnished  with  large  vessels, 
and  formed  a  semi-ellipsoid  measuring  11  mms.  by  10  mms.  On 
incising  this  with  cataract  scissors  it  was  found  to  contain  a 
cavity  distended  by  a  clear  fluid,  and  in  the  fluid  floated  an  em- 
bryo in  the  form  of  a  vermiform  body  1  m.  long,  curved  in  the 
middle  and  swollen  at  one  extremity.  It  was  enveloped  in  an 
excessively  delicate  membrane  by  which  it  was  fixed  to  the  pre- 
sumed chorion, 

Now  of  course  the  whole  conclusion  in  this  case  depends 
upon  the  assumption  that  this  vermiform  body,  only  1  m.  long, 
was  an  embryo.  It  may  have  been  one,  but  certainly  there  is 
no  proof  advanced  in  favor  of  this  view;  and  although  I  am  by 
no  means  prepared  to  deny  its  accuracy,  I  am  certainly  very 
doubtful  about  it.  If  it  was  an  embryo  it  could  only  have  been 
one  of  a  few  hours'  existence,  and  one  could  hardly  expect  to  find 
the  machinery  of  the  whole  process  so  defective  that  the  pavi- 
lion of  the  tube — the  most  important  part  of  the  whole  machinery 
— was  so  damaged  as  to  be.  according  to  M,  Puech's  description, 
almost  closed  and  fixed  behind  the  ovary  by  adhesion.  One 
would  have  at  least  expected  this  adhesion  to  have  been  over  the 
seat  of  the  rupture,  and  yet  it  is  distinctly  stated  not  to  have  been 
so.  I  have  seen  so  many  queer  looking  things  in  ovarian  cysts 
and  follicles  that  I  am  not  inclined  to  admit  that  this  vermiform 
body  has  been  shown  conclusively  to  have  been  an  embryo. 


230  DISEASES   OF   THE   OVAKIES. 

In  another  case,  recorded  by  Walter  in  the  Monatsclirift  fur 
Gehurtshulfe  (vol.  xviii.),  there  is  a  description  of  a  cyst  which 
had  ruptured  and  allowed  the  foetus  to  pass  into  the  abdomen. 
The  cyst  is  stated  to  have  been  an  ovary,  but  the  conditions  of 
the  description  are  not  sufficiently  exact  for  this  to  be  admitted, 
though  it  is  stated  that  the  cyst  was  free  from  adhesions  to  sur- 
rounding parts  and  was  free  from  the  pavilion  of  the  corre- 
sponding tube.  On  the  whole,  I  am  inclined  to  regard  the  evi- 
dence advanced  so  far  concerning  the  alleged  occurrence  of 
gestation  within  the  proper  tissue  of  the  ovary  as  by  no  means 
complete;  and  while  I  am  not  prepared  categorically  to  deny 
its  occasional  occurrence,  as  I  did  in  a  previous  edition  of  this 
book,  yet  I  cannot  admit  that  it  has  been  proved.  Even  if  it 
does  occur  it  would,  as  I  have  said,  possess  little  more  clinical 
importance  than  a  case  of  tubal  pregnancy,  a  differential  diag- 
nosis of  it  could  not  be  made,  and  it  would  have  to  be  treated 
on  the  same  principles  as  the  other  varieties  of  extra-uterine 
pregnancy. 

An  extremely  interesting  contribution  to  the  comparative 
pathology  of  the  ovary  has  been  made  by  Mr.  Henry  H.  Slater, 
in  the  Journal  of  Anatomy  and  Physiology  (vol.  xiii.),  concerning 
an  ovarian  tumor  found  in  a  hen  pheasant.  It  measured  when 
fresh  2.3  inches  in  greatest  length,  1.1  in  breadth,  and  the  same 
in  depth.  It  was  very  irregular  in  form,  and  was  roughly 
divided  into  three  principal  lobes,  which  were  united  at  their 
bases,  and  were  subdivided  into  many  smaller  lobes  ;  the  whole 
presented  the  general  sulcated  appearance  of  a  human  brain  on 
a  smaller  scale. 

The  ovary  seemed  to  be  almost  entirely  absorbed  ;  nothing 
resembling  its  usual  granular  appearance  was  visible ;  and  the 
tumor  rested  consequently  directly  upon  the  kidneys,  a  fold  of 
peritoneum  alone  intervening.  Though  no  ovary  was  visible, 
the  left  oviduct  was  convoluted  as  much  as  it  would  be  in  the 
earlier  part  of  the  breeding  season,  but  this,  of  course,  was  not 
healthy  excitement,  but  due  to  the  inflammation  of  the  organs. 
The  right  oviduct  presented  its  usual  aborted  appearance. 

On  making  a  transverse  section  of  the  tumor,  the  interior  was 
seen  to  be  quite  solid,  and  in  no  degree  cystic  or  alveolar  ;  nor 
was  there,  as  might  have  been  thought  likely,  any  tendency  to 
a  concentric  growth,  but,  on  the  contrary,  bundles  of  fibres  were 
seen  faintly  to  radiate  from  the  point  of  attachment  of  the 
tumor. 

The  minute  anatomy  was  difficult  to  determine,  owing  to  the 
necessity  of  employing  a  high  power.  There  were  visible  fat- 
cells   (by  far  the  largest),   granule-cells,  and  nucleated  cells, 


OVAKIAT^  TUMORS,  CONDITIONS  WHICn  SIMULATE  THEM.      231 

which  I  regard  as  resembling  those  found  in  tubercle — the  last 
named  being  very  numerous  and  irregular  in  shape  and  size. 
Interspersed  were  minute  fibres,  but  these  were  rare;  and  lastly, 
diverging  from  the  base  of  attachment  of  the  tumor,  were  bun- 
dles of  fibres,  very  irregular  in  shape.  To  these  is  due  the 
radiated  appearance  of  the  section.  They  are  unstriated  mus- 
cular fibres,  and  seem  to  be  the  only  remains  of  the  original 
ovary. 

This  diseased  ovary  is  only  the  most  conspicuous  part  of  a 
general  tubercular  affection  which  pervaded  the  whole  of  the 
viscera — the  liver,  pancreas,  omentum,  and  intestines  being  all 
distinctly  more  or  less  involved. 

I  was  under  the  impression  that  the  tumor  was  cancerous, 
from  the  great  resemblance  under  the  microscope  to  medullary 
cancer  of  the  human  ovary ;  and  my  thanks  are  due  to  Profes- 
sor Turner,  who  was  kind  enough  to  suggest  that  the  tumor  was 
probably  tubercular,  the  correctness  of  which  opinion  was  at 
once  verified  by  means  of  dilute  acetic  acid. 


CHAPTER   V. 

OVAHIOTOIVIY. 

In  addition  to  works  and  papers  already  referred  to,  the  fol- 
lowing have  been  consulted: 

Demonstration   eines    Praparates  von   doppelseitiger    Achsendrehung   der   Ovarien. 

Veit.     Arch.  f.  Gyn.,  Vol.  XIII. 
Ueber  Ovariotomie  bei  Kindern.     Schwartz.     Arch.  f.  Gyn.,  Vol.  XIII. 
Zur  Statistik   der  Krankheiten  der  Ovarium.     Runge.       Schmidt's  Jahrbuch,  Vol. 

CLXXVIII. 
Peritonaeale  Metastasen  eines  Eierstocks  dermoids.     Kolaczek.     Virchow's  Archives, 

Vol.  LXVII. 
Ruptur  der  Ovarialcyste.     Nepuen.     Centralblatt  f.  Chir.,  Vol.  II. 
Tod  nach  Function  der  Ovarialcyste.     Boissier.      Centralblatt  f.  Chir.,  Vol.  I. 
Spontane  Ruptur  der  Ovariengeschwulste.     Kryzan.     Centralblatt  f.  Chir.,  Vol.  III. 
Stielbehandlung  Ovariotomie.      KovACS.      Centralblatt  f.  Chir.,  Vol.  III. 
Elektrische  Behandlung  Ovarialtumoren.     Clemens.     Centralblatt!  Chir.,  Vol.  IV. 
Exstirpation  der  Ovarien  bei  starken  Menorrhagie.     Stahl.     Centralblatt  f.   Chir., 

Vol.  IV. 
Ovariotomie.     Tait.     Wegen  Uterinblutungen.     Centralblatt  f.  Chir.,  Vol.  VI. 
Ovariotomien  in  Italien.     Peruzze.      Centralblatt  f.  Chir.,  Vol.  VI. 
Chirurg.  Bemeik.   uber  die  Peritonealhohle  mit    Besonderer    Beiiicksichtigung  der 

Ovariotomie.     Wegner.     Arch,  fur  Klin.  Chir. ,  Vol.  XX. 
Bin   Fall   von   Laparo-Hysterotomie    sammt  Exstirpation    beider  Ovarien,   Heilung. 

WolfI;ER.     Archives  fur  Klin.  Chir.,  Vol.  XXI. 
Ovarialcysten  5  Falle.     Woi.fler.     Arch,  fur  Klin.  Chir.,  Vol.  XXI. 
Kyste  de  I'Ovaire,  Tenleve  par  le  vagin.     Davis.     Bulletin  General.     1875.     Vol.  I. 
Ovariotomie.     Ferrier.     Bulletin  General.     1875.     Vol.  I. 
Ovariotomie    d'un  kyste   ponctionnc   24  fois.      Bouger.     Bulletin  General.     1875. 

Vol.  II. 
Ovariotomie  dans  le  sud-ouest  de  la  France.     DurLONG.     Bulletin  General.     1876. 

Vol.  I. 
Ovariotomie  double.     Bulletin  General.     1876.     Vol.  I. 
Ovariotomie  (Observations).     Tessier.     Bulletin  General.      1876.  Vol.  II. 
Contribution  a  I'aide  de  I'Ovariotoraie.     Dezanneau.     Bulletin  General,  January  15, 

1880. 
Ovariotomie.     Bulletin  General.     Vols.  II.     1878  and  1879. 
Ovariotomie  Indicationen,  etc.     Koeijerle.     Centralblatt  fiir  Gyn.,  Vol.  XI. 
Ovariotomie  Stielbehandlung.     Baum,  etc.     Cent.  f.  Gyn.,  Vol.  XI. 
Ovariotomie  Tetanus.     P.\rvin.     Cent.  f.  Gyn.,  Vol.  XI. 
Ovariotomia  triplex  bei  Ueberzahl  von  Ovarien.    Winkler.    Arch,  f.  Gyn.,  Vol.  XIII. 


OVARIOTOMY.  233 

Tiber  Ovariotomie  bci  Kindern.     Schwartz.     Arch.  f.  Gyn. ,  Vol.  XIII. 
Balneotherapie,  Entziuidung  der  Ovarium.     Flechsig.     Schmidt.     Vol.  CLXX. 
Ovarium  Krebs,  auf  Uterus  u.  Ilectam  iibergreifend  '"Obstet.  Traiie."    1876.   Schmidt, 

Vol.  CLXXVII. 
Fall  Ovariotomie.     RuNGE.     Schmidt.     Vol.  CLXXVIII. 
Death  from  Ovarian  Cancer.     PuiLiPSON.     Lancet,  1877.     Vol.  I. 
Laceration  of  the  Bowel  in  Ovariotomy.     Chambers.     Lancet,  1877.     Vol.  II. 
Exceptionally  Difficult  Case  of  Ovariotomy.     Tait.     Lancet,  1877.     Vol.  II. 
After  History  of  a  Case  of  Ovariotomy.      Tait.     Lancet,  1877.     Vol.  IL 
Ovariotomy  in  France.     Beclahd.      Lancet,  1878.     Vol.  I. 
Ovariotomy.     Who  shall  Perform  it  ?     RuDFORD.     Lancet.  1878.     Vol.1. 
Ovariotomy.     Who  shall  and  Who  shall  not  Perform  it  ?    Editor.     Lancet,  1878.    Vol. 

IL 
Wound  of  Bladder  in  Ovariotomy.     Eustache.     Brit.  Med.  Journal,  1879.     Vol.  II. 
The  Scotsman  on  Ovariotomy.     Editor.     Brit.  Med.  Journal,  1819.     Vol.  II. 
Parthogenetic  Development  of  Cysts  in  the  Ovary.     Tait.     Brit.  Med.  Journal,  1879. 

Vol.  IL 
Castration  of  Women.     Schuckestg.     Med.  Record.     November,  1879. 
Perforating  Ulcer  of  lUum  after  Ovariotomy.     Doran.     Lancet,  1879.     Vol.  I. 
Ovariotomy  during  Peritonitis.     Tibbets.     Med.  Times,  1874.     Vol.  I. 
Ovariotomy  under  Difficulties.      Stevens.     Med.  Times,  1874.     Vol.  I. 
Historical  Sketch  of  Ovariotomy.     Jackson.     Med.  Times,  1874.     Vol.  I. 
The  First  Operation  for  Ovariotomy.     Anon.     Med,  Times,  1874.     Vol.  II. 
Ovariotomy  at  the  London  Surgical  Home.     Baker  Brown.     Lancet,  1862. 
Birth  of  Triplets  after  Ovariotomy.     Balding.     Med.  Times,  1874.     Vol.  II. 
Diagnosis  of  Ovarian  Disease.     Baccelli.     Med.  Times,  1877.     Vol.  I. 
Lister's  Method  in  Ovariotomy.      Sims.     Med.  Times,  1877.     Vol.  I. 
Ovariotomy.     Billroth.     Med.  Times,  1877.     Vol.  II. 
Ovariotomy  during  Pregnancy.     Wells.     Times,  1877.     Vol.  II. 
Elastic  Ligature  in  Ovariotomy.     Kleberg.     Med.  Times,  1877.     Vol.  II. 
Normal  Cases  of  Ovariotomy.     Hegar  and  Battey.     Med.  Times,  1877.     Vol.  II. 
Ovariotomy.     Sims.     Med   Times,  1877.     Vol  II. 

Double  Specimens  of  Ovarian  Cysts      Edis.     Med.  Times,  1878.     Vol   I. 
Unsuccessful    Cases   of   Ovariotomy.     Knowslet   TnoiiNTON.     Med.    Times,    1873. 

Vol.  II. 
Amount  of  Life  saved  by  Ovariotomy.     Wells.     Med.  Times,  1878.     Vol.  II. 
Prohibition  of  Ovariotomy  at  Guy's  Hospital.     Editor.     Med.  Times,  1878.     Vol.  II. 
Monument  to  the  "Father   of  Ovariotomy."     Boston  Journal.     Med.  Times,  1870. 

Vol.  II. 
Ovariotomy.     Treatment  of  Pedicle.      Spiegelberg.     Med.  Times,  1879.     Vol.  I. 
Section  de  I'urethre  pendant  Ovariotomie.     Nussbaum.     Ann.  de  Gyn.     Vol.  VI. 
Ovariotomie  chez  les  femraes  enceintes.     Valcourt.     Ann.  de  Gyn.     Vol.  VIII. 
Ovariotomie.     Traitement  du  Pedicule.      Netzel.     Ann.  de  Gyn      Vol.  IX. 
Indications  et  contre-indications  de  I'Ovariotomie.     Duplay.     Ann.  de  Gyn.     Vol.  X. 
Tumeur  solide  des  deux  Ovaires.     Ferrier  and  Rozzi.     Ann.  Gyn.     Vol.  XI. 
Hernies  de  rOvaire  dans  I'antiquite.     Houze.     Ann.  Gyn.     Vol.  XI. 
Double  Hernia  Ovarialis.     WiRTH.     Archiv.  fiir  Gynekologifi,  1877. 
Amputation  utero-ovarique.      Tarnier.     Ann.  Gyn.     Vol.  XI. 
New  Clamp  for  Ovariotomy.     Dawson.     Amer.  Joum.  Obst.     May,  1875. 
New  Ligature  for  Pedicle  in  Ovariotomy.     Hosmer.    Amer.  Journal  Obst.     May,  1875. 
Diagnosis  of  Ovarian   Tumors.      CiiADWiCK.     Amer.  Journal  Obst.     Vol.  IX. 
Normal  Ovariotomy.     Battey.     Amer  Journal  Obst.     Vol.  IX. 
Therapeutics  of  Ovarian  Tumors.     Feiber.     Amer.  Journal  Obst.     Vol.  IX. 


234  DISEASES   OF   THE   OVARIES. 

Ovariotomy  on  a  Girl  of  Thirteen.     Koeberle.     Amer.  Journal  Obfet      Vol.  IX. 
"No  more  Ovariotomy."     Semeledek.     Atner   Journal  Obst.     Vol.  IX, 
Ovariotomy.     Fibroma  of  the  Ovary.     Atlke.     Amer.  Journal  Obst.     Vol.  IX. 
Dermoid  Cyst  of  Ovary.     Ferkiek.     Amer.  Journal  Obst.     Vol.  IX. 
Ovariotomy  in  a  Child  of  Four.     ScnWAKZ.     Amer.  Journal  Obst.      January,  1879. 
Fluid  of  Polycystic  Ovarian  Tumors.     BucKHAM.     Amer.  Journal  Obst.     April,  1879. 
Multilocular  Cysto-sarcoma.     Engelmann.     Amer.  Journ.  Obst..  Apr  1,  1879. 
Ovarian  Cysts  in  a  Case  of  Extra-Uterine  Foetation.      ScoTT.     Obst.   Trans.    Vol.  XV. 
Suppurating  Tumor  of  Left  Ovary.     Oswald.     Obst.  Journ.,  1875.     Vol.111. 
Drainage  of  Ovarian  Cysts.     Delore.      Obstet.   Journ.     Vol.  IV. 
Ligature  of  Ovarian  Pedicle.     Howe.      Obstet.    Journ.     Vol.  IV. 
Ovariotomy  under  Carbolic  Spray.      Baum.      Obst.   Journ.     Vol.  IV, 
Ovariotomy,  Treatment  of  Pedicle.     Keith.     Obst.  Journ.     Vol.  IV. 
Ovariotomy,  rost-mortcm  Seven  Years  After.     Hr.\iE.      Obst.   Journ.     Vol.  IV. 
Dermoid  Tumor  of  the  Ovary.     FoULis.     Obst.   Journ.      Vol.   IV. 
Rupture  of  Ovarian  Cyst  during  Labor.     Quern.     Obst   Journ.     Vol.  V. 
Vaginal  Drainage  in  Ovariotomy.     Olsiiausen.     Obst.  Journ.     Vol.  V. 
Abdominal  Drainage  in  Ovariotomy.     Hildebrandt.     Obst.  Journ.     Vol.  V. 
Menstruation  after  Double  Ovariotomy.     Verneuil  and  Ferrier.      Obst.  Journ. 

Vol.  V. 
Removal  of  Ovaries.     Ciiambers.     Ob^t.  Journ.     May,  1879.     Vol.  VI. 
Diagnosis  of  Large  Ovarian  Tumors.     Schultze.     Obst.   Journ. ,  October,  1877. 
Dermoid  Cyst  of  Ovary.     Miller.     Glasgow  Medical  Journal,  1876. 
Tapping  of  Ovarian  Cysts.     Kidd.     Dublin  Medical  Journal,  1874. 
Ruptured  Ovary.     Canning.     Dublin  Medical  Journal,  1878. 
Controlling  Temperature  after  Ovariotomy.     Thomas.     Dublin  Medical  Journal,  1879. 

January  to  June. 
One  Hundred  and  Ninety  Cases  of  Ovariotomy.     Keith.     Edinburgh  Medical  Jour- 
nal, 1874-5. 
Ovariotomy  in  Cases  of  Suppurating  Cyst.      Keith.     Edinburgh.  Medical  Journal, 

1874-5. 
Extirpation  of  Kidney.     Campbell.     Edinburgh  Medical  Journrl.     Vol.  XIX. 
Twin  Pregnancy  after  Ovariotomy.     Mazolo.   Edinburgh  Medical  Journal.   Vol.  XIX. 
Ovariotomy  with  Pregnancy.     Hillas.     Edinburgh  Medical  Journal.     Vol.  XXI. 
Ovariotomy  under  Difficulties.     Stevens.     New  York  Medical  Journal      Vol.  XIX. 
Case  of  Normal  Ovariotomy.      Sabine.     New  York  Medic:d  Journal.     Vol.  XXI. 
Ovariotomy  in  Edinburgh.     Keith.     New  York  Medical  Jounaal.     Vol.  XXII. 
Actual  Cautery  in  Ovariotomy.     Keith.     New  York  Medical  Journal.     Vol   XXIII. 
Removal   of   Ovaries   for   Epilepsy.     Battey.     New    York  Medical   Journal.      Vol. 

XXIV. 
Purulent  Cyst  of  Ovary.     Jacobi.     New  York  Medical  Journal.     Vol.  XXV. 
Multilocular  Complicated  Ovarian  Cyst.     New  York  Medical  Journal.      Vol.  XXVI. 
Rupture  of  Ovarian  Cysts  into  Intestines.     New  York  Merlical  Journal.     Vol.  XXVII. 
Ovarian  Cyst  Treated  by  Electrolysis.     Cutter.     New  York  Medical  Journal.     Vol. 

XXVI 1. 
Enucleation  of  Ovarian  Tumor.     Miner.     American  Medical  Journal.     Vol.  LXVII. 
Normal  Ovariotomy.     Thomas.      American  Medical  Journal.     Vol.  LXVII. 
Vaginal  Ovariotomy.     Gilmoke  Reeve.      American  Medical  Journal.     Vol.  LXVII. 
Diagnosis  of  Subacute  Ovaritis.     Tii,T.     American  Medical  Journal.     Vol.  LXVII. 
Ovaries  from  Case  of   Normal   Ovariotomy.      Thomas.     American    Medical   Journal. 

Vol.  LXVIII. 
Ovariotomy   Compared   with   Ilystorotomy.      RiCHET.     American   Medical   Journal. 

Vol.  LXVIIL 


OVAEIOTOMY.  23.J 

Ovulation  without  Menstrnation.     Sinety.   American  Medical  Journal.   Vol.  LXVIII. 
Ovarian  Cyst  Cured  by  Puuctiire.     Vast.     American  Medical  Journal.      Vol.  LXX. 
Ovarian  Cyst,  Menstruation  from  Pedicle.     American  Medical  Journal.     Vol.  LXXi. 
Dermoid  Ovarian  Cysts.    Griffiths  and  BERN UTZ.    Ameiican  Medical  Journal.     Vol. 

LXXIII. 
Pelvic  Adhesions  in  Ovariotomy.    Attlee.    American  Medical  Journal.  Vol.  LXXIII. 
Ovariotomy  During  Peritonitis.     Munde  and  Tait.     American  Medical  Journal.     Vol. 

LXXV. 
Electrolysis  in  Ovarian  Tumors.     Munub.     American  Medical  Journal.     Vol.  LXXVI. 
Ovariotomy,   Ligature  of  Pedicle    Complete.     Doran.     American   Medical  Journal. 

Vol.  LXXVII. 
Drainage  of  Ovarian  Cy.sts.     Stimson.     American  Medical  Journal.     July,  1879. 
Considerations  sor  rOvariotomie.     Wegner.     Arch.  Gen.,  1877.     Vol.  L 
Ovariotomie  normale.     Lxjtaud.     Arch.  Gen  ,  1879.     Vol.1, 
Amputation  utero  Ovarique.     Imbert.     Arch.  Gen.,  1879.     Vol.1. 
Fifty  Cases  of  Ovariotomy.     Tait.     Birmingham  Med.  Review.     Vol.  VIL 
Normal  Ovariotomy.     Editor  Birmingham  Med.  Review.     January,  1879. 
Ovariotomy,  Ligature  of  the  Pedicle.     Doran.     St.  Bartholomew's  Hospital  Reports, 

1877. 
Ovariotomy,  Ligature  of  the  Pedicle.     Doran.     St.  Bartholomew's  Hospital  Reports, 

1878. 
Successive  Stages  of  Ovariotomy.      Doran.      St.  Bartholomew's  Hospital  Reports, 

1878. 
Ovaries  Removed  by  Operation.     Pathological  Transactions,  1874. 
Ovarian  Tumor  in  Girl  of  Ten.     Dickinson.     Pathological  Transactions,  1874. 
Cancers   of    Both   Ovaries   and   Breasts.       Coupland.      Pathological   Transactions, 

1876. 
Ovariotomy  in  Hospitals.     Editor  British  Medical  Journal,  1874.     Vol.  L 
Ovariotomy  in  a  Child.    Wells.     British  Medical  Journal,  1874.     Vol.  L 
Ovariotomy  in  Leeds  Infirmary.   WnEELiiousE.   British  Medical  Journal,  1874.  Vol.  I. 
The  First  Ovariotomy.     Jackson.     British  Medical  Journal,  1874.     Vol.  I. 
Tumor  of  the  Ovary  Removed  by  Enucleation.     Burnham.     British  Medical  Journal, 

1874.     Vol.  i. 
Tumor  of  Kidney  Simulating  Cystic  Ovary.     British  Medical  Journal,  1874.     Vol.  I. 
Disease  of  Ovary.     Campbell.     British  Medical  Journal,  1874.     Vol.  I. 
Fluids  in  Pelvis  after  Ovariotomy.     Keith.     British  Medical  Journal,  1875.     Vol.  I. 
Dropsy  of  Ovary.     Smith.     British  Medical  Journal,  1876.     Vol.  I. 
Suppurating  Tumor  of  Ovary.     Oswald.     British  Medical  Journal,  1873.     Vol.  I. 
Malignant  Disease  of  Ovary.     Charteris.     British  Medical  Journal,  1876.     Vol.  I. 
Prolapse  of  Cyst  of  Ovary.     STOCKS.     British  Medical  Journal,  1876.     Vol.  1. 
Mortality  after  Ovariotomy  in  Dublin.   KiDD.     British  Medical  Journal,  1876.  Vol.  II. 
Enucleation  of  Cysts  of  Ovary.     Miner.     British  Medical  Journal,  1876.     Vol.  II. 
Ovariotomy  in  the  London  Hospitals.    Wells.    British  Medical  Journal,  1877.  Vol.  1. 
Ovariotomy  in  Vienna.     Billroth.     British  Medical  Journal,  1877.     Vol.1. 
Ovariotomy  in  Dublin  Hospitals.     Atthill.     British  Medical  Journal,  1877.     Vol.1. 
Clinical  Lecture  on  Ovariotomy.     Heath.     British  Medical  Journal,  1877.     Vol.  I. 
Aspiration  of  Cysts  of  Ovary.     Edis.     British  Medical  Journal,  1877.     Vol.1. 
Growth  of  Cysts  of  Ovary.     Tait.     British  Medical  Journal,  1877.     Vol.  L 
Spontaneous  Cure  of  Ovarian  Cyst.     Quinby.     Medical  Record,  1876. 
Vaginal  Ovariotomy.     Wing.     Medical  Record,  1877. 
Pus  in  Ovarian  Fluids.     ('HADWICK.     Medical  Record,  1877. 
Medullary  Sarcoma  of  Left  Ovary.     Clemens.     Biennial  Ret.,  1874. 
Ovarian  Menorrhagia.     Meadows.     British  Medical  Journal.     July  12,  1879. 


23G  DISEASi:S    OF   THE    OYAKIES. 

Ovarian  Tumor  Removed  from  Child  of  Two  Years  and  Eleven  Months.  Kidd.  Dub- 
lin Medical  Journal,  February,  1879. 

Ovarian  Cyst  in  a  Child  of  Three  Years  and  Four  Months.  New  York  Medical 
Journal,  January,  1880. 

Relation  of  Diseases  of  Ovarian  Blood-vessels  to  Ovarian  Cysts.  NoEGGERATH.  New 
York  Medical  Journal,  January,  1879. 

Diagnosis  of  Ovarian  Tumors.     Tait.     New  Yoik  Medical  Journal,  April,  1880. 

Considerations  a  propos  de  I'Ovariotoraie.  Tillaux.  Annales  de  Gynecologie. 
March,  1879. 

Relations  of  Disease  of  Blood-vessels  of  Ovary  to  Ovarian  Cysts.  NOEGGERATii. 
American  Journal  of  Obstetrics.     January,  1880. 

Ovarian  Cyst  in  a  New-born  Child.  Tuojias.  American  Journal  of  Obstetrics.  Jan- 
uary, 1879. 

General  Peritonitis— Ovaritis  with  Abscess.  Lusk.  American  Journal  of  Obstetrics. 
January,  1880. 

Ein  Fall  von  Psammocarcinom  des  Ovarium.  Flaischlen.  Virchovv's  Arch.,  Jan- 
uary, 1879. 

Krebs  (auf  beiden  Seiten).     Breisky.      Schmidt.     January,  1879. 

Zur  diagnostischen  Punktiou  bei  abdom.  Cysten.  Spiegelbeug.  Schmidt.  April, 
1880 

Ucber  die  Exstirpation  extra  peritoneal  gelogerter  Ovarial  und  parovarial  geschwulste. 
MiJLLER.      Schmidt.     April,  1880. 

Antiseptic  Theory  and  Ovariotomy.  (Paper  and  discussion.)  Tait.  Lancet.  Feb- 
ruary 14th  ;  also  Medical  Times,  February  28,  1880. 

Ovariotomy;  Abscess  Opening  into  Intestine.     Moore.     Lancet,  February  28,  1880. 

Two  Cases  of  Oophorectomy.     Ewkn.s.     British  Medical  Journal,  January  ol,  1880. 

Case  of  Ovariotomy  in  the  Sixth  Month  of  Pregnancy.  Galabin.  British  Medical 
Journal,  March  13. 

Ovariotomy  in  New  York  and  London.  Sims,  etc.  British  Medical  Journal,  1877. 
Vol.  II. 

Drainage  in  Ovariotomy.     Bantock.     British  Medical  Journal,  1877.     Vol.  II. 

Ovariotomy  During  Pregnancy.     British  Medical  Journal,  1877.     Vol.  II. 

Suppuration  of  Tumor  of  Ovary.     Bennet.     British  Medical  Journal,  1878.     Vol.  I. 

Lectures  on  Ovariotomy.     Wells.     British  Medical  Journal,  1878.     Vol.  II. 

Ovariotomy  in  General  Hospitals.     Editor.     British  Medical  Journal,  1878.     Vol.11. 

Ovariotomy  During  Pregnancy.     Smith.     British  Medical  Journal,  1878.     Vol.  II. 

Ovariotomy  Before  and  After  Antiseptics.  Keith.  British  Medical  Journal,  1878. 
Vol.  II. 

Remarks  on  Ovariotomy.     Nussbaum.     British  Medical  Journal,  1878.     Vol.   II. 

Cyst  of  Ovary.     Hayes.     British  Medical  Journal,  1878.     Vol.11. 

Opinion  on  Ovariotomy.     Hdntbr.     Medical  Press,  1875.     Vol.  I. 

Vitality  of  Ova.     Colasantir.     Medic  il  Press,  1876.      Vol.  I. 

Dispersion  of  Ovarian  Cysts  by  Klectncity.    Eiirenstein.    Medical  Press,  1877.  Vol.1. 

Complication  in  Ovariotomy.     MrciiAUX.     Medical  Pre.ss.  1877.     Vol.1. 

Ovariotomy  and  Hysterotomy.     RicilKT.     Practitioner.     Vol.  XII. 

Double  Ovariotomy,  Transfusion  of  Milk.  Gaillard  Thomas.  Practitioner.  Vol. 
XX.   (45;}). 

Dermoid  Tumors  of  Ovaries.     Byi'ORD.     Medical  News  and  Library,  1878. 

Sarcoma  Mista'en  for  Ovarian  Tumor.     Cremonksis.     Medical  Ronord,  1875. 

Ovariotomy  ;  Battey's  Operation.     Yandell  and  McClellan.    Medical  Record,  1875. 

Drainage  in  Ovariotomy.     Paum.     Medical  Record.  1875. 

Ovariotomy  in  a  Girl  of  Thirteen.     Koebehle      Medical  Record,  1876. 

Ovariotomy  during  Septicaimic  Fever.     Peruzzi.     Medical  Record,  1876. 


OVARIOTOMY.  237 

Ovariotomy  during  Pregnancy.     Baum.     Medical  Record,  1876. 

Tetanus  after  Ovariotomy.     Bantock.     British  Medical  Journnl,  April  17. 

Summary  of  Fifteen  Cases  of  Battey's  Operation.  Battey.  British  Medical  Journal, 
April  ;5,  1880. 

Thomas  Keith  and  Ovariotomy  (paper  on).  Marion  Sims.  Boston  Medical  and 
Surgical  Journal,  March  4,  1880. 

Ovariotovny  ;  Death  from  Internal  Hemorrhage.  Homans.  Boston  Medical  and  Sur- 
gical Journal,  March  11,  1880. 

Metro-Peritoneal  Fistula  in  a  Case  of  Successful  Ovariotomy.  Tait.  Lancet,  1875. 
Vol.  I. 

Ovarian  Tumor  Simulating  Extra-uterine  Pregnancy.     Tait.    Lancet,  1S7o.    Vol.11. 

Results  of  the  Cautery  in  the  Treatment  of  the  Pedicle  in  Ovariotomy.  Keitu.  Lan- 
cet, 187G.     Vol.  I. 

Case  of  Battey's  Operation.     Engelmann.     Boston  Medical  Journal,  May  13,  1880. 

On  Oophorectomy.     Savage.     Obstetric  Journal,   May,  1880. 

Oper  ition  do  Porro  (Cases).     Championniere.      Annales  de  Gyn.,  April,  1880. 

Ascite  simulant  un  kyste  de  I'ovaire.     Hinze.     Annales  de  Gyn.,  April,  1880. 

High  Temperature  after  Aseptic  Ovariotomy.  Thornton.  British  Medical  Journal, 
May  1,  1880. 

Listerian  Method  in  Ovariotomy.     Tait.     Medical  Times,  June  26,  1880. 

Three  Cases  of  Ovariotomy  during  Pregnancy.  Pippingskold.  American  Journal 
of  Obstetrics,  April,  1880. 

Earliest  Age  at  which  Ovarian  Cysts  are  Found.  Jenkins.  American  Journal  of  Ob- 
stetrics     April,  1880 

Intestinal  Obstruction  Pedicle  of  Ovarian  Cyst  around  Ileum.  Henry.  American 
Journal  of  Obstetrics      April,  1880. 

Battey's  Operation  in  Epileptoid  Affections.  Sims.  Meclical  Record.  New  York, 
June  5,  1880. 

True  Import  of  Oophorectomy  in  Epilep.sy,  etc.  Fallen.  Medical  Record.  New 
York,  June  5,  1880. 

Ovarian  Cyst  repeatedly  Ruptured.     Meredith      Lancst.     December  20,  1879. 

Drainage-tubes  in  Ovariotomy.     Bantock.     Med.  Times.      1879.      Vol.  II.,  p.  24. 

Etranglement  interne— kyste  ovarique.     Julliard.     Ann.  de  Gyn.     January,  1880. 

Case  of  Detached  Ovary.     Peaslee.     American  Journal  of  Obstetrics.     Vol.  XI. 

Ovariotomy  with  Fibroid  Tumor  of  Ovary.  Goodell.  American  Journal  of  Obstet- 
rics. Vol.  XI. 

Ovarian  Cyst  in  an  Infant.     Leduc.     New  York  Medical  Journal,  1879.     Vol.,  II. 

An  Account  of  a  Drop.sy  in  tho  Left  Ovary  of  a  Woman,  aged  Fiftv-eight,  Cured  by  a 
Large  Incision  made  in  the  Side  of  the  Abdomen,  by  Dr.  Robert  Houston. 
Philosophical  Transactions.     Vol.  XXXIII.     London,  1724. 

Cases  of  Dropsical  Ovaria,  Removed  by  the  Large  Abdominal  Section,  by  D.  Henry 
Walne,  Surgeon.     London,  1843. 

Another  Case  by  same  Author.     Medical  Gazette,  1844. 

History  and  Statistics  of  Ovariotomy.  Lynam.  Proceedings  of  Massachusetts  Medi- 
cal Society,  18."»5. 

Removal  of  a  Dropsical  Ovarium  by  George  Southam.  London  Medical  Gazette, 
1847. 

Ovarian  Dropsy.  Dr.  Frederick  Bird.  Medical  Times  and  Gazette.  Vols.  XXIV., 
XXV. ,  and  XXVI. 

Six  Cases  of  Ovarian  Dropsy.     Dr.  Jeafpreson.     Medical  Gazette,  1844. 

The  Results  of  all  the  Operations  Performed  for  the  Extirpation  of  Diseased  Ovaria 
by  the  Large  Incision,  from  September  12,  1842,  to  the  Present  Time.  Charles 
Clay,  M.D.     Manchester,  1848. 


238  DISEASES   OF   THE   OVARIES. 

Ovariotomy.     J.T.Simpson.     Monthly  Journal  of  Medical  Science.     January,  1816. 
Removal   of    Diseased    Ovaria,    by  Ephraim  McDowell.     Eclectic    Repertory   and 

Analytic  Review.     Philad^lphia,  1816. 
Simpson's  Obstetric  Works.     Priestley  &  Stoker.     Edinburgh,  1855. 
Resultats  Statistiques  de  L'OvariOuOmie.     E.  Koeberle.      Paris,  1868, 
Thomas  Keith  and  Ovariotomy.     J.  M.a.rion  Sims.     New  York,  1880. 
Lettre  d' Abraham  Cyprianus.     T.  Middleton.     Amsterdam,  1707. 
Beitriige  zur  Vervollkoraraung  der  Heilkunde.     DzoNDi.     Halle,  1816. 
Histoire  de  la  Societe  Royale  de  Medicine.     L'Aumonier.     Vol.  V.,  1783. 
De  la  Porte  et  Morand.     Memoires  de  I'Academie  de  Chirurgie.     Vol.  II. 
Ueber  extirpation  Krankhafter  Eierstocke.     HoPFER.     Graefe  and  Walter's  Journal. 

Vol.  XII.      (for  Chrysmar's  case). 
Medical  Observations  and  Enquiries.     WiLLlAM  Hunter,  1762. 
Lecture  on  Ovariotomy.     Du.  Charles  Clay.     Edinburgh  Medical  Journal,  1857. 

It  is  characteristic  of  every  advance  which  has  been  made  in 
surgery,  as  in  all  other  human  affairs,  that  the  early  phases  are 
developed  with  extreme  slowness,  so  that  in  perusing  the  history 
of  any  surgical  progress  it  is  almost  certain  that  we  should  have 
to  go  a  long  way  back  to  see  the  first  germs  of  the  movement.  I 
have,  I  believe,  examined  very  exhaustively  the  literary  history 
of  ovariotomy,  but  I  can  find  no  record  of  any  deliberate  attempt 
to  relieve  a  patient  from  ovarian  dropsy  by  opening  the  abdomen 
earlier  than  the  year  1701.  It  is  a  singular  and  striking  illus- 
tration of  the  slow  progress  made  by  any  new  idea,  that,  so  late 
as  1861,  an  operation  which  was  successfully  performed  by  Rob- 
ert Houstoun,  of  Glasgow,  one  hundred  and  sixty  years  before, 
should  have  been  characterized  by  one  of  the  leading  surgeons 
of  his  time  as  ^n  operation  which  ought  to  subject  its  perfor- 
mer to  a  criminal  indictment  for  manslaughter.  I  can,  how- 
ever, well  remember,  in  the  days  when  I  was  a  student  at  Edin- 
burgh, one  of  the  favorite  subjects  for  discussion  in  the  students' 
medical  societies  was  the  doubtful  point  of  ovariotomy  being  a 
justifiable  operation,  and  now,  when  I  find  my  mortality  varying 
from  three  to  five  per  cent.,  it  sometimes  seems  to  me  as  if  these 
discussions  were  but  ill-remembered  dreams;  for  it  must  be  ad- 
mitted there  is  no  important  operation  which  has  received  the 
same  hostile  criticism,  the  same  searching  scrutiny,  or  finally 
has  achieved  the  same  triumphant  admittance  as  ovariotomy. 
Its  critics  have  subjected  it  to  a  statistical  ordeal  through  Avhich 
no  other  surgical  operation  has  passed,  and  it  is  the  only  one 
which  has  achieved  a  legitimate  and  complete  establishment. 

The  merit  of  being  the  first  to  utter  an  opinion  in  favor  of 
the  radical  cure  of  ovarian  dropsy  has  usually  been  ascribed  to 
William  Hunter,  but  Houstoun's  operation  was  performed  seven- 
teen years  before  Hunter's  birth,  and  so  far  as  the  history  of  tliis 
question  has  been  unearthed,  I  think  the  whole  merit  must  be 


OVARIOTOMY.  239 

given  to  the  Glasgow  surgeon.  So  important  do  I  regard  this  as 
being  the  first  case,  that  I  give  at  length  what  information  I  have 
been  able  to  obtain  concerning  this  most  interesting  man  and  the 
details  of  his  operation.  For  much  of  this  I  am  obliged  to  Mr. 
Alexander  Duncan,  of  Glasgow. 

Robert  Houstoun  was  the  son  of  a  Glasgow  surgeon  of  the 
same  name,  who  held  the  office  of  Visitor  of  the  Faculty  of  Phy- 
sicians and  Surgeons  of  Glasgow  in  16G9,  and  again  in  1G77,  this 
oflS.ce  being  virtually  that  of  President  of  the  Surgeons.  Robert 
Houstoun  the  younger  was  regularly  apprenticed  to  his  father  in 
1665,  this  being  before  the  days  of  the  existence  of  any  medical 
schools  in  Scotland,  and  it  is  probable  he  had  few  other  oppor- 
tunities of  making  himself  acquainted  with  the  surgical  art  than 
those  afforded  him  by  his  seven  years'  apprenticeship  to  his 
father.  At  its  expiration  he  became  a  member  of  the  Faculty 
and  began  to  practise  in  Glasgow  as  a  "surgeon-apothecary," 
or  general  practitioner. 

In  1691  he  was  himself  elected  Visitor  of  the  Faculty,  an 
honor  which  was  more  than  once  renewed,  so  that  it  becomes 
perfectly  clear  that  in  his  native  city  he  was  at  a  very  young 
age  a  person  of  distinction,  and  probably  an  operating  surgeon  of 
large  experience.  In  1697  he  took  an  active  part  in  forming  a 
collection  of  medical  works,  which  was  the  nucleus  of  the  present 
library  of  the  Glasgow  Faculty.  The  "  list  of  such  worthie  per- 
sonnes  "  as  contributed  to  this  collection,  with  the  names  of  the 
works  gifted  by  each,  has  been  preserved,  and  under  Houstoun's 
name  stands  a  considerable  list  of  donations.  Of  these  some  are 
no  longer  in  the  library,  but  others  of  them,  bearing  his  auto- 
graph, are  still  to  be  found  on  its  shelves. 

In  1711  he  appears  to  have  contemplated  the  somewhat  risky 
step  of  retiring  from  general  practice  and  limiting  himself  to  the 
work  of  a  physician.  Houstoun's  is  the  first  case  in  Glasgow  of 
such  a  practice,  and  his  example  was  followed  by  only  some 
three  or  four  others  in  the  course  of  the  eighteenth  century,  of  men 
withdrawing  into  the  quiet  of  purely  consulting  practice  after 
having  made  their  positions  as  general  practitioners.  To  accom- 
plish this  object  of  his  ambition  Houstoun  required  to  obtain 
the  degree  of  Doctor  of  Medicine,  a  distinction  which  had  been 
acquired  by  three  or  four  of  his  townsmen  by  residence  abroad, 
usually  at  Utrecht  or  Leyden.  Houstoun,  however,  resolved  to 
gain  his  degree  from  the  University  of  his  native  city,  which  had 
the  power  of  granting  such  degrees  even  though  it  had  no  medi- 
cal school,  and  was  entirely  destitute  of  a  medical  faculty.  In 
1711  he  applied  to  be  admitted  to  examination  for  the  degree,  but 
it  does  not  appear  that  the  University  authorities  cared  to  com- 


240  DISEASES   OF   THE   OVARIES. 

ply  with  his  request,  for  we  find  in  the  Archives  of  the  Univer- 
sity a  minute  dated  31st  December  of  tliat  year,  that  "  Mr. 
Robert  Houstoun,  surgeon,  who  sometime  agoe,  applyed  for  the 
Doctorat  in  Medicin  did  still  insist  that  he  might  be  examined 
in  order  to  his  graduation.  The  Faculty  considering  that  they 
might  still  want  Professors  of  Medicin  doe  appoint  some  of  the 
Physicians  in  the  city  to  assist  at  the  examination."  Before  this 
extra-academical  board  Houstoun  passed  his  trials  successfully 
on  January  3,  1712,  and  Mr.  Duncan  has  favored  me  with  an 
extremely  interesting  extract  from  the  records  of  the  examina- 
tion of  this  remarkable  candidate. 

Shortly  after  graduating,  and  probably  between  the  years 
1713  and  1715,  Houstoun  seems  to  have  found  the  field  offered  for 
his  ambition  in  Glasgow  too  restricted,  and  he  was  induced  to 
attempt  the  larger  field  of  the  English  metropolis.  In  London 
it  is  probable  that  he  practised  as  a  general  practitioner,  for  in 
the  thirty-third  volume  of  the  "  Philosophical  Transactions," 
page  388,  he  mentions  that  he  was  engaged  in  the  practice  of 
midwifery,  and  of  course  no  London  physician  would  be  so  en- 
gaged at  that  time.  All  his  published  works  tend,  however,  to 
show  that  the  bent  of  his  mind  still  lay  in  the  direction  of  sur- 
gery, and  chiefly  of  abdominal  surgery.  In  1720  he  published  a 
controversial  pamphlet  entitled  ''Animadversions  on  a  late 
Pamphlet  entitled  Lithotomia  Douglasiana,"  and  in  172G  ap- 
peared his  "  History  of  Ruptures  and  Rupture  Cures." 

In  1722  he  contributed  to  the  Royal  Society  "An  Account  of 
a  Case  of  Extra-Uterine  Foetus,  taken  out  of  a  Woman  after 
Death."  In  this  case  it  is  extremely  noteworthy  that  he  had 
proposed  to  operate  during  the  life  of  the  patient,  and  his  offer 
had  been  declined;  had  it  been  accepted,  this  remarkable  man 
would  have  ranked  as  the  first  operator  in  such  a  case,  and  it  is 
possible  he  might  have  been  the  first  successfully  to  interfere  in 
this  displacement.  In  1724  he  read  before  the  Royal  Society  the 
case  upon  which  his  reputation  was  chiefly  founded,  and  which 
formed  the  first  case  of  ovariotomy.  For  this  paper  he  was 
elected  a  Fellow  of  the  Royal  Society  in  the  following  year.  He 
died  in  London,  on  May  15,  1734,  about  the  age  of  seventy,  so 
we  may  estimate  that  his  birth  took  place  about  the  year  1654. 
Unfortunately,  I  have  not  been  able  so  far  to  obtain  any  account 
of  his  life  and  doings  while  in  London,  save  that  he  practised 
somewhere  about  what  was  then  the  West  End.  His  case  of 
ovariotomy  is  entitled  "An  Account  of  a  Dropsy  of  the  Left 
Ovary  of  a  Woman  aged  Fifty-eight,  Cured  by  a  Large  Incision 
made  in  the  Side  of  the  Abdomen  by  Dr.  Robert  Houstoun,"  and 
the  following  is  the  gist  of  his  description  of  his  operation: 


OVARIOTOMY.  241 

"  I  found  this  tumor  grown  to  so  monstrous  a  bulk,  that  it  en- 
grossed the  whole  left  side  from  the  umbilicus  to  the  pubes,  and 
stretched  the  abdominal  muscles  to  a  great  degree.  It  drew 
toward  a  point.  From  being  obliged  to  lie  continually  on  her 
back,  she  was  grievously  excoriated,  which  added  much  to  her 
sufferings,  which,  together  with  a  want  of  rest  and  appetite,  had 
greatly  emaciated  her. 

"The  operation  of  puncturing  the  abdomen  being  proposed, 
she  consented:  accordingly,  with  an  imposthume  lancet  I  laid 
open  about  an  inch,  but  finding  nothing  issue  I  enlarged  it  two 
inches,  and  even  then  nothing  came  forth  but  a  little  thin,  yel- 
lowish serum,  so  I  ventured  to  lay  it  open  about  two  inches 
more.  I  was  not  a  little  startled  after  so  large  an  aperture  to 
find  only  a  glutinous  substance  bung  up  this  orifice.  The  diffi- 
culty was  how  to  remove  it :  I  tried  my  probe  and  endeavored 
with  my  fingers,  but  it  was  all  in  vain,  it  was  so  slippery  that  it 
eluded  every  touch  and  the  strongest  hold  I  could  take. 

"I  wanted  in  this  place  almost  everything  necessary,  but  be- 
thought of  a  very  odd  instrument,  yet  as  good  as  the  best  in  its 
consequence,  because  it  answered  the  end  proposed.  I  took  a 
strong  fir-splinter,  such  as  the  poor  in  that  country  use  to  burn 
instead  of  candles;  I  wrapped  about  the  end  of  this  splinter  some 
loose  lint,  and  thrust  it  into  the  wound,  and  by  turning  and 
winding  it  I  drew  out  above  two  yards  in  length  of  a  substance 
thicker  than  any  jelly,  or  rather  like  glue  fresh  made  and  hung 
out  to  dry;  its  breadth  was  above  ten  inches;  this  was  followed  by 
nine  full  quarts  of  such  matter  as  is  met  with  in  steatomatous  and 
atheromatous  tumors,  with  several  hydatides,  of  various  sizes, 
containing  a  yellowish  serum,  the  least  of  them  larger  than  an 
orange,  with  several  large  pieces  of  membrane,  which  seemed  to 
be  parts  of  the  distended  ovary.  I  then  squeezed  out  all  I  could 
and  stitched  up  the  wound  in  three  places,  almost  equidistant ; 
I  was  obliged  to  make  use  of  Lucatellus'  balsam,  to  cover  a 
pledget,  the  whole  length  of  the  wound,  and  over  that  laid  sev- 
eral compresses,  dipped  in  warm  French  brandy;  and  because  I 
judged  that  the  parts  might  have  lost  their  spring  by  so  vast 
and  so  long  a  distention,  I  dipped  in  the  same  a  napkin  four  times 
folded  and  applied  it  over  all  the  dressings,  and  with  a  couple  of 
strong  towels  which  were  also  dipped,  I  swathed  her  round  the 
body,  and  then  gave  her  an  opiate  medicine,  which  was  ordered 
to  be  repeated  at  intervals. 

"  She  afterward  mended  apace,  to  the  admiration  of  every  one, 
and  lived  in  perfect  health  from  that  time,  which  was  in  August, 
1701,  till  October,  1714,  when  she  died  in  ten  days'  sickness." 

It  may  be  said  that  Houstoun  began  this  operation  with  the 
10 


242  DISEASES    OF    THE    OVAKIES. 

intention  of  doing  little  more  than  relieving  the  patient  by  a 
tapping,  but  I  presume  that  the  first  man  who  put  a  kettle  on 
the  fire  had  no  intention  of  evolving  a  steam-engine  from  the 
simple  process  of  boiling  water  ;  yet  the  discovery  of  how  to  boil 
water  was  by  far  the  most  important  of  all  the  phases  through 
which  the  invention  of  the  steam-engine  has  passed.  There  can 
be  no  question  from  Houstoun's  description  that  he  had  diag- 
nosed a  dropsy  of  the  ovary  and  that  he  had  to  deal  with  a  con- 
dition which  is  often  one  of  the  most  difficult  that  can  be  met 
with  in  the  performance  of  ovariotomy,  and  he  completed  his 
operation  by  removing  the  cyst.  Although  he  does  not  describe 
his  division  of  the  pedicle,  or  his  having  tied  it,  it  is  almost  cer- 
tain that  he  did  both.  He  certainly  must  have  seen  and  divided 
the  pedicle,  for  he  describes  the  disease  as  being  of  the  left 
ovary,  therefore  he  saw  the  pedicle.  Perhaps  he  tore  it  and  it 
did  not  need  tying.  That  he  performed  a  complete  ovariotomy 
is  certain,  from  his  having  noticed  secondary  cysts  as  well  as 
from  the  recovery  of  his  patient  and  the  fact  that  she  lived  for 
thirteen  years  afterward,  in  perfect  health. 

William  Hunter  and  his  brother  John  Hunter  must  have 
known  of  Houstoun's  case,  for  they  were  born  and  brought  up  in 
the  district  in  which  it  occurred,  and  William  Hunter  lived  for 
years  in  the  city  near  which  it  was  performed.  They  both  ad- 
vocated the  tiieory  of  the  performance  of  the  operation,  and 
John  Hunter  is  reported  to  have  said  :  "  I  cannot  see  any  reason 
why,  when  the  disease  can  be  ascertained  in  an  early  stage,  we 
should  not  make  an  opening  into  the  abdomen  and  extract  the 
cyst.  Why  should  not  a  woman  suffer  spaying  as  other  ani- 
mals do  ?  The  merely  making  an  opening  into  the  abdomen 
would  never  be  followed  by  death  in  consequence  of  it  ?  " 

Their  friend  John  Bell,  who  practised  in  Edinburgh  from 
1790  till  181G,  also  pronounced  in  favor  of  its  performance,  but 
he  is  not  known  to  have  done  anything  toward  trying  it  himself, 
and  it  is  to  a  young  Scotchman,'  who  was  a  pupil  of  John  Bell's 
in  1703,  that  we  owe  the  revival  of  the  operation  and  its  perform- 
ance upon  a  scale  which  amounted  to  that  of  a  legitimate  experi- 
ment. Ephraim  McDowell  has  been  honored  by  the  medical 
profession  in  America  as  the  ''Father  of  Ovariotomy,"  and 
whether  we  admit  the  accuracy  of  the  title  or  not,  there  can  be 
no  doubt  that  it  was  in  the  backwoods  of  Kentucky  that  ab- 
dominal surgery  received  one  of  its  greatest  impulses.    In  1809  the 

'  My  American  readers  may  object  that  McDowell  was  not  born  in  Scotland.  Of 
this,  however,  we  are  not  yet  clear.  At  any  rate,  bis  father  and  mother  were  Scotch, 
and  at  the  time  of  his  birth,  1771,  the  States  did  not  exist. 


0VAK10T03IY.  243 

second  ovariotomy  was  performed  successfully  and  the  patient 
survived  it  thirty-two  years.  In  1817  Dr.  McDowell  published  an 
account  of  these  and  of  two  other  cases  he  had  performed,  and,  as 
might  be  expected,  his  statements  were  received  with  general 
incredulity.  The  editor  of  the  British  and  Foreujn  Medical  and 
Chirurgical  Review  was  bold  enough  to  distinctly  deny  the  credi- 
bility of  McDowell's  statements,  but  in  1S27,  when  the  authen- 
ticity of  the  accounts  had  been  established  beyond  doubt,  he  had 
the  manliness  to  "beg  pardon  of  God  and  of  Dr.  McDowell  of 
Danville "  for  his  hardiness.  The  operation  was  performed 
twelve  times  in  all  by  Dr.  McDowell,  with  a  mortality  of  thirty- 
three  per  cent.,  and  in  one  other  case  he  failed  to  complete  the 
operation. 

Lizars  tells  us  that  about  ISIG  Dr.  McDowell  sent  his  manu- 
script to  John  Bell,  at  Edinburgh,  for  his  perusal.  At  that  time 
the  great  surgeon  had  gone  to  Rome,  suffering  from  his  fatal 
illness,  and  the  manuscript  was  read  by  John  Lizars,  who  was 
doing  John  Bell's  work.  This  accounts  for  Lizars  being  the  first 
to  follow  in  Houstoun's  footsteps  in  Scotland,  and  it  affords  a 
curiously  sequent  history  of  the  early  phases  of  this  notable  sur- 
gical success. 

In  1822,  Nathan  Smith,  of  New  Haven,  performed  an  operation 
successfully,  and  in  1823  Lizars  made  his  first  attempt,  but  un- 
fortunately he  had  made  a  mistake  and  there  was  no  tumor. 
Nathan  Smith's  case  was  undoubtedly  one  of  parovarian  cyst, 
and  the  operation  was  therefore  not  an  ovariotomy  at  all.  It  is 
notable,  however,  for  the  facts  that  he  used  the  short  incision  and 
the  short  ligature.  The  curious  fact  that  so  many  of  these  early 
successful  cases  were  parovarian  tumors  makes  me  believe  that 
a  great  many  more  true  ovariotomies  were  done,  of  which  there 
are  no  records,  for  they  probably  all  died.  Parovarian  cysts 
now  are  removed  without  any  risk  at  all.  I  have  never  lost  a 
single  case.  It  is  therefore  very  likely  that  they  formed  the 
early  successes.  On  February  27,  1825,  Mr.  Lizars  removed 
an  ovarian  tumor  successfully,  using  the  long  ligature.  On 
March  22d  of  the  same  year  he  removed  another,  using  the 
short  ligature,  but  his  patient  died.  In  his  fourth  case  he  could 
not  remove  the  tumor,  but  the  patient  recovered  from  the  incom- 
plete operation.  He  concludes  his  account  of  these  cases  with 
the  remarkable  sentence:  ''From  these  cases,  it  appears  that 
there  is  little  danger  to  apprehend  in  laying  open  the  abdominal 
cavity;  and  that  in  diseased  ovarium,  extra-uterine  conceptions, 
foetus  in  utero,  with  deformity  of  the  pelvis  preventing  embryul- 
cia,  aneurism  of  the  common  or  internal  iliac  arteries,  or  of 
the  aorta,   volvulus,  internal  hernia,  and  foreign  bodies  in  the 


244  DISEASES    OF   THE   OVARIES. 

stomach  threatening  death,  we  should  have  recourse  early  to 
gastrotomj.  The  delay  in  such  cases  is  more  dangerous  than 
the  operation."  It  has  taken  fifty  years  to  establish  the  justice 
of  this  opinion. 

Dr.  Granville,  of  London,  operated  twice  in  1827,  and  it  is  gen- 
erally stated  that  both  of  his  cases  were  unsuccessful,  but  in  a 
volume  of  notes  made  by  the  late  Dr.  T.  H.  Tanner,  now  in  my 
X^ossession,  and  written  in  his  own  remarkably  neat  writing,  I 
have  found  a  note  to  the  effect  that  one  of  Dr.  Granville's  cases, 
performed  March  21,  1827,  was  successful,  but  I  do  not  know 
upon  what  authority  this  note  is  made. 

For  some  ten  or  twelve  years  after  the  death  of  McDowell^ 
and  after  the  failures  of  Lizars,  ovariotomy  seems  by  common 
consent  to  have  been  discontinued.  In  March,  1836,  Dr.  Jeaffre- 
son,  of  Framlingham,  removed  a  parovarian  tumor  successfully 
through  an  incision  only  an  inch  and  a  half  long  ("  Transactions 
Provincial  Medical  Association,  1837''),  and  it  is  an  interesting 
fact  that  Mr.  R.  C.  King,  of  Saxmundham,  assisted  at  this  opera- 
tion, for  he  shortly  afterward  described  two  cases  of  successful  re- 
moval of  similar  tumors.  In  1838,  Mr.  Crisp,  of  Harleston,  and  Mr. 
West,  of  Tunbridge  {Lancet,  1837-8),  also  had  successful  cases,  but 
they  were  clearly  all  parovarian,  and  not  ovarian  tumors.  On 
November  G,  1842,  Mr.  D.  Henry  Walne  performed  three  opera- 
tions, all  of  which  were  successful,  and  published  them  as  ovari- 
otomies; but,  singularly  enough,  in  not  one  of  these  cases  was  the 
tumor  removed  an  ovarian  cystoma.  Mr.  Walne  gives  a  figure 
of  the  first  of  his  cases,  and  he  so  thoroughly  describes  the  ap- 
pearances of  the  other  two  that  no  doubt  can  exist  that  they 
were  parovarian  cysts,  and  it  is  not  clear  whether  he  did  or  did 
not  remove  the  ovaries  with  them.  On  October  19,  1843,  he  re- 
moved a  tumor  which  was  undoubtedl}^  of  ovarian  origin,  but 
unfortunately  the  i)atient  died.  His  method  of  operating  was 
very  curious,  and  to  us  now  would  seem  very  ghastly,  but  still  he 
deserves  the  credit  of  a  pioneer.  He  tells  us  his  incisions  were 
fourteen  or  fifteen  inches  long,  and  that  they  were  extended  bit 
by  bit  until  the  tumor  slipped  out  of  them;  that  is  to  say,  a  paro- 
varian cyst,  which  might  have  been  removed  by  a  two-inch  in- 
cision after  being  tapped,  was  allowed  to  deliver  itself,  with  its 
wall  unbroken,  tlirough  an  incision  which  was  made  large 
enough  to  accommodate  it. 

On  September  27,  1842,  Dr.  Charles  Clay,  of  Manchester,  who 
may  in  all  truth  be  regarded  as  the  "  Father  of  Ovariotomy  "  as 
far  as  Europe  is  concerned,  performed  his  first  operation  for  the 
removal  of  a  diseased  ovary.  He  had,  on  the  twelfth  of  the  same 
month,  performed  another  operation,  but  here  again   there  is 


OVAKIOTOMY.  245 

abundant  evidence  to  show  that  a  parovarian  was  mistaken  for 
an  ovarian  tumor.  Previous  to  September,  1842,  we  have  there- 
fore records  of  only  two  ovariotomies,  properly  so  called,  in  this 
<jountry,  those  of  Houstoun  and  Lizars. 

In  184:3,  Mr.  Aston  Key  removed  both  ovaries,  and  Mr.  Bransby 
Oooper  also  tried  the  operation  in  that  year,  but  it  was  not  till 
1844  that  there  was  a  successful  case  in  London,  operated  on  by 
Dr.  Frederick  Bird,  followed  by  one  in  the  practice  of  Mr.  Lane. 
In  the  provinces,  however,  many  successful  cases  had  been  done, 
and  the  metropolis  was,  not  for  the  only  time,  behindhand.  Dr. 
Clay  continued  to  operate  with  very  remarkable  success  for 
many  years  until  he  had  performed  three  liundred  and  ninety- 
five  operations  with  one  hundred  and  one  deaths,  his  total  mor- 
tality being  therefore  about  twenty-five  per  cent.  His  operations 
were  witnessed  and  alluded  to  by  some  of  the  most  distinguished 
practitioners  of  the  time,  and  yet  Clay  has  received  an  amount 
of  adverse  criticism,  and  his  statements  have  been  received  with 
an  incredulity  which  is  as  undeserved  as  it  is  unworthy  of 
those  from  whom  it  came,  and  wliich  arose  solely  from  the  fact 
of  his  being  a  provincial  surgeon.  Looking  back  upon  the  work 
of  a  generation  now  almost  passed,  from  a  standpoint  altogether 
free  from  personal  bias,  I  have  no  hesitation  whatever  in  ascrib- 
ing to  Dr.  Clay  by  far  the  larger  share  of  the  credit  which  arises 
from  the  enormous  advances  made  in  abdoininal  surgery  during 
the  last  forty  years.  It  is  quite  true  that  McDowell  was  the  first 
to  do  a.  number  of  ovariotomies,  and  it  is  equally  true  that 
Houstoun  was  the  first  successfully  to  remove  a  diseased  ovary, 
hut  it  was  Clay,  of  Manchester,  who  first  showed  that  ovari- 
otomy could  be  made  an  operation  more  justifiable  by  its  results 
than  any  of  the  major  operations  of  surgery.  His  methods  were 
imperfect,  as  are  the  methods  of  all  pioneers,  but  it  was  upon 
his  work  that  the  foundation  was  laid  for  all  those  brilliant  re- 
sults we  now  attain.  I  say  this  with  all  the  more  readiness  now 
that  Dr.  Clay  is  far  advanced  in  life,  and  that  but  lately  a  most 
unfair  and  ungenerous  attempt  has  been  made  to  deprive  him  of 
his  just  merit,  though  perhaps  I  might  have  left  it  unsaid,  as 
Dr.  Clay  has  shown  himself  quite  capable  of  his  own  defence. 
In  Sir  J.  Y.  Simpson's  Lectures,  published  in  the  Medical  Times 
and  Gazette,  1859-61,  there  is  the  following  evidence  on  behalf 
of  Dr.  Clay:  '"'Indeed,  the  revival  of  it  is  principally  due  to  the 
exertions  and  example  of  Dr.  Clay,  of  Manchester,  who  has 
himself  operated  now  in  ninety-three  cases."  Bryant,  in  his 
book  on  '"Ovariotomy"  (18G7),  entitles  Dr.  Clay  "the  first  great 
apostle  of  ovariotomy  in  this  country."  Peaslee  remarks  in  his 
work  on  "Ovarian  Tumors,"  ""to  him,  more  than  to  all  other 


246  DISEASES   OF   THE   OVARIES. 

operators  the  credit  belongs  of  having  placed  the  operations  of 
ovariotomy,  on  a  sure  foundation. " 

One  of  the  most  conspicuous  defects  of  his  method  of  pro- 
ceeding was  the  employment  of  v^hat  is  called  the  long  liga- 
ture— that  is  to  say,  he  tied  the  pedicle,  returned  it  into  the  ab- 
domen, and  left  the  ligatures  hanging  out  of  the  v^ound,  as  w^as 
done  by  McDowell  and  Walne.  Had  he  cut  these  ligatures 
short,  and  completely  closed  the  wound,  I  have  no  doubt  that 
instead  of  having  a  mortality  of  twenty-five  per  cent,  it  would 
speedily  have  fallen  to  six  or  eight  per  cent. 

The  great  improvement  which  was  effected  upon  Clay's 
method  was  that  which,  curiously  enough,  had  been  employed 
twenty  years  before  by  Nathan  Smith,  but  which  was  neglected 
until  reintroduced  and  firmly  established  by  the  late  Mr.  Baker 
Brown,  and  to  this  most  able  but  most  unfortunate  surgeon  I  un- 
hesitatingly award  the  position  of  having  achieved  the  second 
great  advance  in  abdominal  surgery.  He  began  to  operate  in 
1851,  and  his  career  ended  in  18(37.  He  established  the  short  in- 
cision, the  intraperitoneal  method  of  dealing  with  the  pedicle, 
the  use  of  the  actual  cautery  for  its  treatment,  and  the  complete 
closure  of  the  abdominal  wound.  Between  May,  18(35,  and  Sep- 
tember, 18G7  (that  is,  during  the  time  when  he  employed  the 
cauter}'),  he  performed  forty  operations  upon  these  principles, 
with  four  deaths,  or  a  mortality  of  ten  per  cent.  During  the 
same  period  Mr.  Spencer  Wells  operated  one  hundred  and  one 
times  with  twenty-six  deaths;  or  a  mortality  slightly  over  twenty- 
five  per  cent.  Verily  ovariotomy  would  liave  had  a  very  differ- 
ent history  during  the  last  fourteen  years  if  Mr.  Baker  Brown 
had  not  fallen  a  victim  to  his  own  folly,  or  professional  jeal- 
ousy— for  opinions  differ  very  much  as  to  the  cause  of  his  death. 
His  methods,  again,  were  in  many  respects  faulty,  and  have 
since  been  immensely  improved  upon;  but  I  give  these  details 
concerning  the  result  of  his  practice  because  here  again  a  most 
unfair  attempt  has  been  made  to  deprive  a  man  of  the  credit  he 
has  deserved;  and  however  much  Mr.  Baker  Brown's  actions  in 
other  respects  are  to  be  deplored,  and  however  much  he  may  or 
may  not  have  deserved  his  sudden  and  disastrous  downfall,  he 
does  deserve  to  rank  second  in  order  of  English  ovariotomists. 

The  following  letter  from  Dr.  T.  Keith  {British  Medical  Joiir- 
iKil,  July  31,  1880)  gives  very  important  evidence  upon  this  point 
in  the  history  of  ovariotomy: 

"Simple  experience  with  the  clamp  alone  did  little  to  dimin- 
ish this  mortality  ;  for,  in  Mr.  "Wells'  published  eight  hundred 
cases,  tlie  death-rate  in  the  last  three  hundred  was  greater  than 
in  the  preceding  three  Imndred.     His  results  by  the  dropped  liga- 


OVARIOTOMY.  247 

ture  were  even  worse — thirty-eight  per  cent.  All  over  the  fright- 
ful mortalit}"  of  one  in  four  continued  ! 

'•'For  some  time  past  it  has  seemed  to  me  that,  had  Baker 
Brown  lived,  the  history  of  this  operation  since  1804  would  have 
been  different.  His  own  method  of  dealing  with  the  pedicle  by 
the  cauter}^  at  once  lowered  the  mortality  to  one-half  of  that 
with  the  clamp,  and  it  was  becoming  practised  in  London  when 
illness  came  to  him,  and  death.  The  man  and  his  method  were 
quickly  forgotten;  no  one  would  have  the  lesson  his  work  gave. 
All  were  strangely  blind  in  those  days  to  its  value.  Should  I  not 
rather  say,  we  were  all  strongly  prejudiced  ?  In  truth,  there  is 
no  more  startling  page  in  surgical  history  than  that  in  which 
his  latest  results  are  given.  On  one  page  we  have  almost  noth- 
ing but  failures;  on  the  other,  by  a  simple  change  in  the  method 
of  operating,  an  almost  uninterrupted  line  of  success.  During 
the  whole  of  his  professional  life  he  seems  to  have  tried  hard  to 
cure  ovarian  disease.  From  1851  to  1864  he  made  many  efforts 
and  tried  many  ways,  all  in  vain,  till  he  adopted  the  cautery. 
His  published  results  show  a  mortality  of  less  than  one  in  ten  in 
completed  cases.  I  have  read  somewhere  that  he  lost  but  four 
of  his  last  fifty  operations.  Some  years  afterward — unable  to 
get  my  mortality  much  under  the  one  in  five,  for  I  was  then  ig- 
norant of  drainage — I  took  to  Mr.  Brown's  method  in  a  sort  of 
despair.  For  a  time  it  was  used  irregularly,  and  only  in  the  worst 
cases,  or  in  those  not  favorable  for  the  clamp.  The  results  of  the 
first  fifty  cautery  cases,  published  in  the  Lancet,  gave  a  mortality 
of  less  than  one  in  twelve — eight  per  cent.,  and  the  results  that 
followed  were  much  better.  Mr.  Wells  and  Mr.  Thornton  have 
lately  given  their  statistics  of  cases  performed  under  careful 
antiseptic  treatment,  and  with  all  the  other  improvements  of 
these  later  years,  and  the  mortality  is  nearly  eleven  per  cent. 

"  So  much  for  Mr.  Baker  Brown's  as  compared  with  the  other 
methods.  But,  after  all,  what  concerns  us  most  now  is,  by  whose 
method  may  ovariotomy  be  performed  with  the  least  risk  to  the 
patient  ?  Surely  the  one  that  gave  us  a  death-rate  of  less  than 
eight  per  cent.,  long  before  antiseptics  were  heard  of,  is  the 
one  to  trust  to  now — such,  at  least,  is  my  experience.  The  cautery 
alone  gave  the  best  results  of  all  the  methods  before.  It  gave  bet- 
ter results  fifteen  years  ago  than  any  other  method  can  yet  show 
with  antiseptics.  Helped  by  drainage — for  where  would  the  an- 
tiseptic system  be  without  drainage  ? — it  gives  the  best  of  all  re- 
sults with  them.  Ninety-eight  of  m^^  last  hundred  cautery  opera- 
tions have  recovered,  and  in  one  of  the  two  fatal  cases  the  tumor 
was  malignant  with  cancerous  matter  in  the  pelvis,  practically 
an  incomplete  operation. 


248  DISEASES   OF   THE   OVAEIES. 

"  Have  I  not  reason,  therefore,  for  saying  that,  had  Mr.  Baker 
Brown  lived,  the  history  of  ovariotomy  since  18G4  would  have 
been  changed;  and  that,  in  making  his  calculations.  Lord  Sel- 
bourne  would  have  had  to  add  three  times  the  number  of  years 
to  the  lives  of  women  saved  by  ovariotomy  ?  " 

In  1858  Mr.  Spencer  Wells  began  his  work,  and  in  his  third 
operation  he  adopted  the  clamp  as  a  method  of  dealing  with  the 
pedicle,  and  this  he  retained  in  all  suitable  cases  until  about  1878. 
During  this  time  he  performed  G27  operations  with  the  clamp, 
having  a  mortality  of  20.73  per  cent.  During  the  same  period 
he  operated  157  times  w^ith  the  ligature,  with  a  mortality  of  38.2 
per  cent.,  and  on  this  point  it  is  to  be  noted  that  he  retained  the 
intraperitoneal  method  only  for  those  cases  to  which  he  could  not 
apply  the  clamp.  I  mention  this  here  merely  to  indicate  my  opin- 
ion that  the  introduction  of  the  clamp  was  a  decidedly  retro- 
grade step  in  the  history  of  ovariotomy.  When  I  began  my  ow^i 
practice,  in  18G7,  I  employed  the  ecraseur,  a  variety  of  the  in- 
traperitoneal method,  and  my  results  over  a  limited  experience 
were  extremely  good.  Like  others,  however,  I  was  so  impressed 
with  the  overwhelming  experience  of  Mr.  Wells,  that  I  resorted 
to  the  clamp,  and  my  results  with  it  were  so  bad  that  its  employ- 
ment will  ever  be  to  me  a  matter  for  bitter  and  lasting  regret. 

In  his  lectures  before  the  College  of  Surgeons  Mr.  Wells 
gives  the  following  account  of  his  results  : 

''With  regard  to  the  proportion  of  deaths  to  recoveries,  tak- 
ing my  own  cases  only  as  a  starting-point,  of  the  500  cases  pub- 
lished in  my  book,  373  recovered  and  127  died — a  mortality  of 

25.4  per  cent  of  the  300  subsequent  cases,  published  in  1873,  in 
the  paper  at  the  Royal  Medical  and  Chirurgical  Society,  223  re- 
covered and  77  died — a  mortality  of  25.  G  per  cent.  Since  the  800 
cases,  I  have  now  operated  on  exactly  100  more,  making  a  total 
of  900  complete  operations.  Of  the  last  100,  83  recovered  and  17 
died — a  mortality  of  17  per  cent.  Adding  the  whole  900  cases 
together  we  have  679  recoveries  and  221  deaths — a  mortality  of 

24.5  per  cent.  It  is  satisfactory  that  in  the  last  series  of  100 
cases  the  mortality  is  tlie  least." 

In  the  last  hundred  cases  I  believe  some  seventy-five  or  eighty 
were  dealt  with  by  the  ligature,  and  nothing  could  be  more  con- 
demnatory of  the  clamp  than  such  figures,  which  show  that 
after  using  it  more  than  six  hundred  times  in  selected  cases, 
Mr.  Wells  could  not  bring  his  mortality  below  twenty  per 
cent.,  whereas,  fourtet^n  years  before,  Mr.  Baker  Brown  had  a 
mortality  of  only  ten  i)er  cent,  with  the  intraperitoneal  method. 

In  18G2,  Dr.  Thomas  Keith  began  his  operations  in  Edinburgh, 
and  he  speedily  found,  as  he  tells  us,  that  the  results  obtained 


OVARIOTOMY.  249 

by  the  clamp  were  extremely  bad,  and  he  reintroduced,  and  by 
his  brilliant  work  has  completely  re-established,  the  intraperito- 
neal method  of  Baker  Brown.  With  the  clamp  his  mortality 
was  19.2  per  cent.,  which  is  close  upon  that  of  Mr.  Wells,  20.73  ; 
with  the  cautery,  on  the  other  hand,  out  of  156  cases  Dr.  Keith 
has  had  a  total  mortality  of  only  3.85  per  cent.,  and  in  addition 
to  this  it  can  be  shown  by  his  constantly  diminishing  mortality 
that  with  each  series  of  operations  his  increased  skill  diminished 
his  death-rate,  so  that  in  his  fifth  series  of  fifty  cases  he  had  a 
mortality  of  only  eight  per  cent.  No  such  progressive  improve- 
ment is  seen  in  Mr.  Wells'  627  cases  of  clamp  treatment. 

Just  as  this  is  written  I  have  completed  a  series  of  a  hundred 
cases  performed  without  any  of  Mr.  Lister's  so-called  antiseptic 
processes,  and  in  all  of  which  the  pedicle  was  treated  by  the 
•'Staffordshire  knot."  Only  two  of  these  hundred  cases  have 
proved  fatal,  and  in  both  cases  death  was  due  to  the  fact  that 
they  had  been  repeatedly  tapped. 

Dr.  Keith  {British  Medical  Journal,  October  19,  1878)  attrib- 
utes his  success  to  four  conditions,  of  which  he  speaks  as  follows: 

"  1.  To  drainage  of  the  abdominal  cavity  in  severe  cases  by  a 
large  perforated  glass  tube  going  to  the  bottom  of  the  pelvis.  It 
is  to  Koeberle  that  I  am  indebted  for  the  idea.  He  kindly  gave 
me  two  of  his  small  tubes  in  1866.  These  were  soon  found  to  be 
too  narrow  and  too  short.  They  got  easily  choked  with  clot  or 
lymph.  For  the  last  ten  years,  I  have  used  the  large  glass  tubes 
now  in  common  use.  Till  I  had  learned  in  what  cases  to  drain, 
the  tube  was  used  in  alternate  cases  of  the  severe  operations.  I 
am  as  certain  as  I  am  of  my  existence,  that  had  I  used  them 
earlier  and  oftener  the  mortality  would  have  been  less  by  one- 
third.  These  tubes  I  supplied  to  ovariotomist  friends  in  all 
parts  of  the  world,  though  no  one  used  them,  so  far  as  I  know, 
till  attention  was  called  to  drainage  by  the  vagina  by  Dr.  Marion 
Sims — a  method  which  seems  to  me  to  be  one  calculated  rather 
to  give  rise  to  blood-poisoning  than  to  save  the  patient  from  it. 
It  is  remarkable  that  the  only  year  in  which  the  mortality  of  the 
Samaritan  Hospital  fell  to  10  per  cent,  was  in  1876,  when  drain- 
age by  these  glass  tubes  was  first  generally  used.  2.  To  the  use 
of  the  cautery  in  dividing  the  pedicle,  as  proposed  and  practised 
by  the  late  Mr.  Baker  Brown.  How  the  lesson  given  by  his  last 
results  has  been  so  systematically  ignored  in  London  has  always 
been  a  marvel  to  me.  3.  To  the  employment  of  Koeberle's  com- 
pression forceps,  in  large  numbers,  whereby  loss  of  blood  is  pre- 
vented. His  model  is  still  the  best,  notwithstanding  the  clumsy 
imitations  of  it  lately  invented.  4.  To  the  substitution  of  ether 
for  chloroform  in  my  last  two  hundred  and  thirty  operations, 


250  DISEASES   OF   THE   OVARIES. 

whereby  the  after-vomiting  is  avoided,  and  the  risk  of  hemor- 
rhage when  the  wound  is  closed  diminished.  All  these  things 
have,  I  think,  helped  to  lessen  the  mortality,  but  the  drainage 
and  the  employment  of  the  cautery  in  the  division  of  the  pedicle 
have  contributed  most." 

'•  I  wish,  for  the  credit  of  my  small  hospital,  which  I  carried 
on  almost  entirely  at  my  own  expense,  to  make  this  statement 
of  results  distinctly;  and  I  would  not  make  it  prominent  now, 
but  that  year  after  year  the  authorities  of  the  Samaritan  Hospi- 
tal proclaim  in  their  reports,  in  the  largest  of  Roman  letters — 
though  one  of  the  surgeons  tells  me  that  he  has  objected  to  the 
statement  in  vain — that  the  results  got  there  are  always  the  best 
that  have  yet  been  obtained,  the  mortality  of  the  Samaritan 
Hospital  down  to  the  end  of  1876  being  nearly  one  death  in  every 
four  operated  on;  of  the  last  five  corresponding  years,  one  in 
five." 

At  this  period  the  history  of  ovariotomy  entered  upon  a  new 
phase  by  the  introduction  and  application  of  w^liat  is  called  the 
antiseptic  theory  and  the  Listerian  method  of  putting  this  theory 
in  practice.  Keith's  results  without  this  method  w^ere  so  bril- 
liant as  to  put  all  other  efforts  in  the  shade,  and,  startled  by  them, 
with  one  consent  we  followed  in  his  footsteps.  In  my  own  prac- 
tice the  mortality  fell  from  twenty-five  per  cent. ,  which  seems  to 
be  the  normal  rate  following  the  use  of  the  clamp,  to  seven  or 
eight  percent.,  which  seems  about  the  rate  possible  when  Baker 
Brown's  practice  is  followed.  An  attempt  was  made  by  Mr.  Spen- 
cer Wells  and  his  assistant,  Mr.  Tliornton,  to  cover  their  retreat 
from  the  use  of  the  clamp  by  claiming  for  the  Listerian  method 
the  merit  of  the  reduced  mortality;  but  in  the  proper  place  I  shall 
give  reasons  which  have  fully  convinced  me  that  it  is  to  Mr. 
Baker  Brown  and  to  Dr.  Keith,  but  certainly  not  to  Mr.  Lister, 
that  we  owe  our  recent  and  most  brilliant  results  in  this  depart- 
ment of  surgery. 

In  the  preface  to  Mr.  AVells'  first  book  on  '*  Diseases  of  the 
dvaries,"  and  again  in  his  second  edition  in  1878,  there  is  the  fol- 
lowing sentence.  "  Dr.  Clay  had  steadily  continued  in  the  ca- 
reer which  he  began  in  1842,  but  his  operations  not  being  per- 
formed in  a  hospital,  before  numerous  professional  witnesses, 
and  no  connected  series  of  his  cases  being  published,  his  example 
had  but  little  influence." 

These  words  are  again  used  in  an  anonymous  article  upon  the 
history  of  ovariotomy  in  the  Bn'ti.sli  Medical  Journal  for  July 
17, 1880,  and  I  think  they  give  a  very  unfair  representation  of 
the  value  of  Dr.  Clay's  work.  They  convey  the  impression, 
whether  intended  or  not,  tliat  the  writer  considers  Dr.  Clay's 


OVARIOTOMY.  251 

statements  concerning  his  cases  are  not  to  be  trusted,  but  for  my 
own  part  I  am  perfectly  satisfied  that  there  is  not  the  slightest 
reason  for  any  such  aspersion.  It  is  quite  true  that  Dr.  Clay's 
cases  were  performed  in  private  practice,  but  if  this  is  to  be  a 
ground  for  suspicion  of  their  authenticity,  then  at  least  half  of 
the  contributions  made  to  medical  literature  may  be  equally 
doubted.  We  might  just  as  well  turn  round  and  doubt  the  cases 
which  are  credited  to  Dr.  Ephraim  McDowell;  and  the  statement 
made  by  Mr.  Wells  that  Dr.  Clay  did  not  publish  any  "connected 
series  "  is  not  correct,  for  he  not  only  published  a  pamphlet,  from 
which  I  have  quoted,  and  of  which  I  possess  a  copy,  but  in  1857 
he  published  a  table  in  which  he  gave  the  results  of  fifty-one 
operations.  In  his  first  twenty  there  was  a  mortality  of  forty 
per  cent.,  in  the  second  twenty  about  thirty  percent,  mortality, 
while  in  the  last  thirty-one  operations  it  fell  to  twenty-five  per 
cent.,  and  that  mortality  was  maintained  by  Mr.  Spencer  Wells 
for  twenty  years  after  the  publication  of  what  I  am  now  quoting 
from.  Further,  in  Dr.  Clay's  publications  and  in  the  publica- 
tions of  others,  it  is  made  perfectly  clear  that  he  had  performed 
his  operations  before  "  numerous  professional  witnesses." 

There  can  be  no  doubt,  therefore,  that  Dr.  Clay's  example  em- 
boldened others  to  follow  in  his  footsteps,  and  to  him  must  be 
given  the  first  rank  amongst  English  ovariotomists  for  the  re- 
vival and  complete  establishment  of  this  most  important  opera- 
tion. It  must  be  borne  in  mind  that,  at  the  time  in  which  Dr. 
Clay  practised,  the  exact  method  of  recording  cases,  particularly 
of  ovariotomies,  which  now  obtains,  had  not  been  introduced 
in  an}^  department  of  practice,  and  even  now  it  is  almost  con- 
fined to  abdominal  surgery.  No  one  seems  to  have  published 
any  cases  with  the  idea  that  at  some  later  date  a  carping  critic 
might  rise  to  assert  that  such  a  case  had  never  existed.  This  is 
a  kind  of  argument  which  has  received  an  almost  universal 
condemnation  amongst  honorable  men,  and  it  is  one  which  can 
only  be  made  by  insinuation,  and  its  authors  dare  not  give  it  by 
direct  statement.  To  Mr.  Spencer  Wells  must  be  given  the  credit 
of  having  introduced  the  exact  statistical  method,  and  this  there 
can  be  no  doubt  had  a  very  large  influence  in  consolidating  both 
professional  and  public  opinion  as  to  the  propriety  of  performing- 
such  operations;  for  it  was  not  till  then  was  there  any  possible 
answer  to  such  criticism  as  that  directed  against  Dr.  Clay.  But 
that  Dr.  Clay  did  not  provide  against  that  kind  of  criticism, 
which  he  probably  never  expected,  forms  no  justification  for  the 
conclusion  that  his  statements  concerning  his  operations  and 
their  results  are  not  quite  as  correct  as  those  of  Mr.  Wells  or  Dr. 
Keith. 


252  DISEASES   OF  THE   OVARIES. 

What  I  have  to  say  of  the  history  of  ovariotomy  may  be  con- 
cluded by  an  expression  of  opinion  that  the  record  of  its  progress 
passes  from  Clay  and  Baker  Brown  to  Keith,  passing  over  alto- 
gether the  unfortunate  interregnum  of  the  clamp  as  something 
deeply  to  be  regretted.  Not  only  by  the  re-establishment  of  the 
intra-peritoneal  method,  but  by  the  successful  teaching  of  the 
necessity  for  the  complete  cleansing  of  the  peritoneum  and  the 
occasional  use  of  the  drainage-tube,  Keith  has  earned  the  lasting 
gratitude  of  humanity. 

The  treatment  of  ovarian  tumors  by  therapeutics  need  not  be 
discussed,  further  than  to  say  that  it  is  limited  to  the  adminis- 
tration of  tonics  to  sustain  the  functions  of  the  patient,  or  to 
correct  some  errant  condition  which  might  diminish  the  chances 
of  success  for  the  surgical  treatment  of  the  case.  Sometimes  we 
are  the  victims  of  singular  coincidences,  which  seem  to  militate 
against  the  general  experience  in  this  matter.  Some  years  ago 
I  was  consulted  by  a  woman  with  an  enormous  unilocular  tumor, 
whose  husband  declined  all  operative  measures.  Some  months 
afterward  she  received  from  the  hands  of  a  physician  some  inert 
placebo,  and  soon  afterward  the  cyst  ruptured  and  its  contents 
were  absorbed.  For  nearly  five  years  she  remained  perfectly 
well  and  then  the  tumor  reappeared.  She  was  admitted  into  a 
large  general  hospital,  was  operated  upon  and  died  in  a  few 
■days.  The  tumor  proved  to  be,  as  I  had  anticipated,  a  parova- 
rian cyst. 

For  the  cure  of  an  ovarian  cystoma  there  is  nothing  known 
to  have  the  slightest  influence  save  an  operation  for  its  removal, 
and  those  patients  who  unfortunately  are  led  to  believe  that  some 
drug  or  other,  or  some  fanciful  form  of  treatment  will  relieve 
them  from  the  necessity  of  an  operative  oi'deal,  are  only  induced 
to  waste  time  which  is  valuable,  and  to  run  risks  which  may  be 
avoided.  On  this  subject  Mr.  Spencer  Wells  observes:  ''But  I 
would  also  say  that  if  the  operation  be  delayed  for  a  time,  she 
should  not  be  subjected  to  any  useless  treatment:  that  it  is  quite 
useless  to  attempt,  by  iodine,  or  bromine,  or  lime,  or  by  gold,  or 
by  any  other  remedy,  to  attempt  to  diminish  the  size  of  the 
tumor  or  to  check  its  growth.  All  that  is  quite  useless,  and 
might  be  very  injurious  to  the  patient." 

Sir  James  Y.  Simpson  expressed  his  experience  in  equally 
strong  terms  when  he  said,  ''he  had  no  belief  whatever  that 
iodine,  or  mercury,  or  muriate  of  lime,  or  aqua  potassa?,  or 
diuretics,  or  deobstruents,  or  aught  else,  were  capable  of  absorb- 
ing and  removing  the  complicated  structure  and  contents  of  a 
multilocular  cystic  tumor  of  the  ovary.''  Mathews  Duncan 
f^ays,  "  We  know  of  no  one  example  of  the  cure,  otherwise  than 


OVARIOTOMY.  253 

by  the  operation  of  Ephraim  McDowell,  of  an  ovarian  dropsy 
properly  so-called;  not  one,  however  many  may  be  found  de- 
scribed, or  whoever  may  be  the  describer.  Cures  by  one  or  more 
tappings,  cures  by  medicines,  cures  by  spontaneous  rupture, 
cures  by  advancing  pregnancy,  have  been,  if  not  mere  egregious- 
mistakes,  almost  certainly  cures  of  parovarian  cysts  whose  his- 
tory, as  already  known,  quite  accords  with  and  explains  such 
erroneous  allegations." 

Of  tapping  I  have  said  as  much  as  I  think  necessary,  but 
here  I  may  repeat  what  every  one  knows  now.  that  it  never  cures 
a  tumor,  and  that  it  only  brings  about  complications.  It  is  my 
firm  belief  that  if  ovarian  and  parovarian  tumors  were  never 
tapped,  but  were  removed  early  in  their  history,  we  should  have 
only  a  casual  mortality  from  the  operation  of  ovariotomy.  Tap- 
ping, therefore,  in  my  practice,  has  become  only  a  palliation  for 
tumors  I  could  not  remove. 

Many  other  plans  have  been  devised  for  the  radical  cure  of 
ovarian  tumors,  but  they  are  now  all  abandoned  in  favor  of  ova- 
riotomy ;  and  such  methods  of  treatment  as  the  injection  of  io- 
dine or  the  establishment  of  fistulous  tracks  can  only  be  justified 
under  very  exceptional  circumstances. 

Before  the  reintroduction  of  the  intra-peritoneal  method  by  Dr. 
Keith,  we  used  to  delay  the  removal  of  an  ovarian  tumor  as  long" 
as  the  patient  could  get  about  comfortably,  and  this  was  justified 
by  the  fact  that  with  the  clamp  we  got  only  about  seventy-five 
per  cent,  of  recoveries.  But  now  that  we  can  get  ninety-five,  and 
when  we  might  get  ninety-nine  per  cent,  of  recoveries  if  there 
were  no  delayed  and  tapped  cases,  my  rule  is  to  remove  an  ova- 
rian tumor  as  soon  as  it  is  discovered,  and  this  will  soon  come  to 
be  the  received  practice.  The  earlier  the  operation  is  performed 
the  more  certain  the  patient  is  to  recover,  for  the  less  likely  are 
there  to  be  any  complications.  However  advanced  a  case  may 
be,  I  never  refuse  to  operate,  for  I  have  seen  some  of  the  most  un- 
promising cases  recover  without  interruption.  Even  when  there 
is  strong  reason  to  believe  that  the  tumor  may  be  complicated 
with  malignancy,  I  make  an  exploratory  incision  to  remove  all 
doubt.  In  this  way  I  find  that  my  proportion  of  exploratory  incis- 
ions is  increasing,  for  whereas  formerly  I  made  an  exploratory 
incision  where  I  thought  the  tumor  might  be  removed  and  where 
I  proved  mistaken,  I  now  make  an  opening  often  where  I  believe 
the  tumor  cannot  be  removed,  and  here  again,  to  my  great  de- 
light, I  am  occasionally  in  error.  An  exploratory  opening  never 
does  any  harm,  and  very  often  does  a  great  deal  of  good,  even 
where  the  tumor  cannot  be  removed,  for  I  have  repeatedly 
known  that  after  this  operation  there  was  no  reaccumulation 


254  DISEASES    OF    THE    OVAKIES. 

of  ascitic  fluid,  where  formerly  it  was  abundant,  and  we  some- 
times see  an  exploratory  incision  arrest  the  progress  of  an  irre- 
movable tumor  for  a  considerable  time.  I  have  now  under  my 
care  a  patient  with  a  large  myxoma  of  the  caecum  whom  an  ex- 
ploratory incision  completely  relieved  from  distressing  symp- 
toms for  nearly  two  years.  Sometimes,  therefore,  I  now  begin 
an  '"'exploratory  incision''  and  end  it  as  an  "'ovariotomy,'" 
while  formerly  I  used  to  start  an  "  ovariotomy  "  only  to  end  it  as 
an  •*  exploratory  incision."'  There  is  only  one  risk  to  a  beginner 
in  this,  that  he  will  have  to  learn  when  to  stop  at  the  mere  ex- 
ploration. To  attempt  the  removal  of  a  tumor  and  not  be  able 
to  finish  it,  is  the  most  fatal  of  all  proceedings,  and  therefore 
the  list  of  incomplete  operations  should  always  be  a  short  one. 

It  is  almost  a  matter  of  routine  in  the  major  operations  of 
surgery,  that  it  should  be  carefully  ascertained  that  the  patient 
is  not  suffering  from  organic  or  serious  functional  disease  of  any 
important  organ,  and  this,  for  ovariotomy,  must  never  be  neg- 
lected. Especial  care  must  be  taken  to  examine  the  condition 
of  the  urine,  for  the  state  both  of  kidneys  and  bladder  is  a  most 
important  factor  in  the  success  of  the  operation. 

I  should  not,  however,  hesitate  to  operate  in  a  case  where 
there  was  even  distinct  indications  of  important  visceral  disease. 
I  have  operated  on  two  patients  with  marked  disease  of  the 
lungs,  and  they  are  both  still  alive  and  one  has  got  nearly  well.  I 
have  operated  in  an  advanced  stage  of  Bright's  disease,  and  the 
patient  recovered,  was  greatly  relieved  of  her  distress,  and  died 
in  the  ordinary  course  of  lier  kidney  disease.  Any  visceral  lesion 
which  can  be  remedied  before  the  operation  should  of  course 
be  put  right,  and  this  is  most  particularly  true  of  the  bladder. 
If  there  is  any  chronic  catarrh  of  that  organ  it  should  be  curt'd 
before  the  operation,  for  as  the  catheter  has  in  many  cases  to  be 
used  for  some  days.  t]iis  condition  will  almost  certainly  prove 
serious. 

When  an  operation  lias  been  determined  upon  and  every  care 
taken  that  any  defect  discovered  has  been  rectified,  we  come  to 
discuss  the  stag(!S  of  the  operation,  the  precautions  to  be  taken 
before,  and  the  treatment  to  be  followed  after  it.  First  of  all, 
there  is  the  position  of  the  patient — where  shall  she  be  ?  Expe- 
rience answers  that  tlie  more  nearly  her  surroundings  resemble 
those  in  a  healthy  private  house  the  better  ;  and  the  statistics 
show  that  the  performance  of  ovariotomies  in  a  large  general 
hospital  is  altogether  unjustifiable.  There  is  no  operation  in  the 
whole  range  of  surgery  where  the  patient  seems  to  be  so  apt  to 
be  infected  by  septic  influence's,  and  no  precautions  against  them 
can  be  too  great.     For  any  surgeon  to  perform  un  ovariotomy 


OVAKIOTOMY.  255 

while  he  is  engaged  in  dissection  or  in  the  performance  of  post- 
mortem examinations,  or  while  he  is  attending  any  case  from 
which  he  may  be  likely  to  convey  septic  infection,  should  there- 
fore be  looked  upon  as  a  professional  offence  of  the  gravest 
kind. 

Mr.  Spencer  Wells  has  always  expressed  his  views  very 
strongly  upon  this  subject,  and  they  are  well  summed  up  in  his 
lectures  at  the  College  of  Surgeons.  "  Only  two  days  ago,"  he 
says,  ''one  of  the  most  distinguished  of  the  rising  surgeons  of 
the  day  told  me  that  he  had  gone  straight  from  a  post-mortem 
examination  to  operate  for  strangulated  hernia,  quite  confident 
that  the  spray  and  washing  the  hands  with  carbolized  water ' 
would  make  him  safe.  This  undue  confidence  in  antiseptics 
may  lead  to  danger  rather  than  safety,  and  so  far  I  see  no  rea- 
son for  altering  the  opinion  I  expressed  at  Manchester  last  year, 
that  '  for  my  part  I  would  rather  operate  in  a  clean,  quiet,  well- 
warmed,  and  well-ventilated  building,  be  it  large  or  small,  with- 
out any  antiseptic  precautions,  than  run  the  risk  of  trusting  to 
the  neutralizing  or  destructive  power  of  chlorine  or  iodine,  sul- 
phur or  tar,  borax  or  the  permanganates,  salicylic  or  any  other 
acid,  in  a  place  tainted  by  the  presence  of  sewer-gas,  or  the 
seeds  of  some  infectious  or  contagious  disease.' " 

As  we  have  now  had  abundant  opportunities  of  showing  that 
the  so-called  "antiseptic  system,"  even  when  carried  out  to  its 
full,  gives  no  such  absolute  immunity  from  septic  poison  as  is 
claimed  for  it,  this  kind  of  teaching  requires  to  be  placed  in 
prominence,  and  therefore  I  add  my  own  opinion,  in  a  quotation 
from  a  paper  recently  read  before  the  Royal  Medical  and  Chirur- 
gical  Society  : 

"  Some  of  the  warmest  supporters  of  the  antiseptic  system 
uphold  it,  on  the  ground  that  under  its  protecting  influence  oper- 
ations can  now  be  undertaken  successfully  which  formerly  were 
impossible,  such  as  laying  open  joints,  etc.  But  I  desire  to  point 
out  that  this  is  an  argument  which  cuts  both  ways,  and  which 
seems  to  me  to  form  one  of  the  great  dangers  of  antiseptic  sur- 
gery. The  immense  favor  with  which  the  antiseptic  system  has 
been  so  widely  received,  is  most  undoubtedly  due  to  the  fulness 
of  its  promise  as  a  royal  road  to  surgical  success,  as  a  something 
which  puts  the  skilled  and  the  competent  upon  a  level  with  the 
inexperienced  and  incompetent  ;  and  I  know  that  there  have 
been  abundant  instances  of  bitter  lessons  already,  that  even  an 
antiseptic  spray  will  not  condone  the  want  of  manipulative  dex- 
terity or  the  absence  of  readiness  in  emergency. 

'"  There  is,  further,  an  inevitable  result  in  the  full  acceptance 
of  this  germ-theory  adaptation,  that  the  other  factors — the  con- 


256  DISEASES   OF   THE   OVARIES. 

dition  of  the  patient  and  his  surroundings — will  be  relegated  to 
unimportant  positions,  and  we  shall  have  a  great  risk  of  inducing 
an  inattention  to  general  hygiene  and  the  incursion  of  rash  expe- 
riment, which  will  do  more  harm  than  antisepticism  will  do  good, 
even  if  everything  claimed  for  it  is  true.  That  this  is  no  fancy 
sketch  is  proved  by  what  Mr.  Spencer  Wells  narrated  in  his  lec- 
tures at  the  College  of  Surgeons  on  abdominal  surgery.'' 

I  can  only  say  further  that  in  my  opinion  any  man  who  delib- 
erately performs  an  operation  under  circumstances  from  which 
his  patient  acquires  fatal  blood-poisoning  ought  to  be  the  subject 
of  a  criminal  indictment. 

I  am  also  strongly  of  opinion  that  no  surgeon  engaged  in  con- 
stant attendance  on  the  promiscuous  cases  admitted  to  a  general 
hospital  should  perform  such  an  operation  as  ovariotomy,  and  I 
look  on  it  as  mere  foolhardiness  on  the  part  of  any  one  to  per- 
form it  to  whom  it  will  probably  never  occur  again  to  engage 
with  such  a  case,  or  whose  experience  is  likely  to  be  limited  to 
two  or  three  such  cases  in  a  lifetime.  It  is  an  operation  beyond 
all  others  requiring  that  readiness  of  adaptation  for  emergencies 
which  wide  experience  alone  can  give.  Its  complications  are  far 
more  varied  and  tax  far  more  heavily  the  courage  and  presence 
of  mind  of  the  operator  than  those  of  any  other  operation  in  sur- 
gery; and  one  or  two  successful  cases  scarcely  compensate  for 
those  which  are  unsuccessful  by  lack  of  experience. 

It  may  be  urged  against  these  views  that  they  are  merely  the 
opinions  of  a  specialist,  and  therefore  represent  only  a  limited  in- 
terest; but  my  experience,  were  I  permitted  to  detail  it,  would 
be  sufficient  not  only  to  convince  my  readers  that  my  views  are 
well  founded,  but  that  they  really  represent  the  best  interests 
alike  of  the  public  and  of  the  surgical  profession.  To  any  mem- 
bers of  my  profession  who  may  be  inclined  to  argue  this  point 
let  me  put  the  question  as  to  whom  they  would  entrust  their 
wives  or  sisters  for  the  removal  of  an  ovarian  tumor — to  a 
surgeon  engaged  in  general  practice,  whose  experience  of  these 
cases  was  limited  to  some  half  dozen  cases  with  some  two  or 
three  deaths,  or  to  one  who  engaged  in  this  kind  of  work  only 
and  diminished  in  every  way  all  risks  of  infection,  at  the  same 
time  that  he  increased  his  special  experience  ?  The  fact  is,  as 
Simpson  very  well  showed  in  1845,  it  was  to  a  large  extent  be- 
cause the  operation  was  not  made  a  specialty  that  it  was  so 
long  in  receiving  professional  acceptance.  "  The  diagnosis  and 
the  operation  were,  under  the  existing  divisions  and  arrange- 
ments of  practice,  undertaken  by  two  different  sets  of  practi- 
tioners— the  former  by  the  obstetric  physician,  and  the  latter  by 
the  operating  surgeon.     It  was,  perhaps,  the  only  capital  opera- 


OVARIOTOMY.  257 

tion  in  which  the  surgeon  was  required  to  proceed  upon  the  diag- 
nostic knowledge  of  another  party;  and  no  one  was  to  be  blamed 
if  he  felt  a  natural  repugnance  to  incur  so  serious  a  responsibility 
on  such  grounds." 

It  was  mainly  this  which  made  Mr.  Syme  hold  out  so  strenu- 
ously against  the  operation  and  refuse,  to  the  end  of  his  life,  to 
perform  it,  even  after  Dr.  Keith  had  shown  what  splendid  results 
could  be  obtained  in  Mr.  Syme's  own  city.  By  common  consent 
it  is  being  handed  over  to  special  practitioners,  for  whom  no  spe- 
cial name  has  yet  been  coined,  and  whilst  the  department  of  ob- 
stetrics is  being  retained  by  physicians,  abdominal  surgery  is 
passing  over  to  the  surgeons. 

The  room  in  which  the  operation  is  to  be  performed  should  be 
fairly  large,  and  so  arranged  that  ventilation  may  be  possible 
from  window  or  door  to  the  fireplace  without  the  current  cross- 
ing the  bed  of  the  patient.  There  should  be  no  unnecessary  fur- 
niture, and  as  little  upholstery  work  as  possible.  Two  small 
iron  couches,  with  firm  hair-mattresses  and  a  water-pillow,  are 
needed:  and  an  intelligent  woman  for  nurse,  who  will  do  as  she 
is  told,  and  nothing  more,  is  absolutely  essential.  If  two  such 
can  be  got  to  act  as  relays  for  the  first  eighty  hours  after  the 
operation,  it  will  be  found  a  great  advantage. 

For  my  hospital  practice  I  have  now  arrangements  altogether 
different  from  those  of  my  earlier  experience,  and  the  results  are 
correspondingly  good. 

The  patient  herself  requires  a  little  preparation  for  the 
change  that  is  about  to  be  made  in  her  alvine  actions.  For  this 
purpose,  I  direct  that  her  food  should  be  limited  to  soup  and  a 
very  little  bread  for  forty-eight  hours  before  the  operation,  and 
that  on  the  morning  of  the  day  previous  she  shall  have  a  small 
dose  of  castor-oil.  The  elaborate  preparations  which  were  in 
vogue  twenty  years  ago,  of  both  the  patient  and  her  surround- 
ings, are  now  quite  abandoned. 

I  prefer  that  the  room  should  have  a  northern  light,  that  the 
day  should  be  clear,  and  I  have  the  patient  placed  on  a  firm,  nar- 
row table  with  her  feet  directed  against  the  window.  The  arms 
and  legs  are  secured  by  bands  to  the  table,  so  that  only  one  assist- 
ant is  required,  one  person  to  give  the  anaesthetic,  and  one  nurse 
to  look  after  the  sponges.  All  other  bystanders  are  earnestly 
requested  to  do  nothing  unless  specially  desired,  and  above  all 
not  to  speak  during  the  operation.  My  assistant  is  duly  in- 
structed in  his  work,  and  I  never,  if  I  possibly  can  help  it,  operate 
with  any  but  my  usual  assistant,  for  it  is  quite  as  important 
that  he  should  know  how  to  help  me  as  it  is  that  I  should  know 
how  to  operate.  All  the  preparations  of  the  instruments  and 
17 


258 


DISEASES    OF   THE   OVARIES. 


sponges  I  make  myself,  and  then  I  am  sure  nothing  is  forgotten 
— or  if  anything  should  be  omitted,  I  have  only  myself  to  blame. 
As  a  successful  ovariotomy  is  the  resultant  of  a  large  number 
of  petty  details  carefully  attended  to,  no  amount  of  care  and 
precision  can  be  too  great  in  carrying  them  out. 

The  instruments  to  be  provided  are,  a  perfectly  sharp  scalpel, 
twelve  of  Koeberle's  scissor-forceps,  four  handled  needles 
threaded  with  two  thicknesses  of  silk,  two  pairs  of  cyst-forceps, 
a  pair  of  large  screw  bull-dog  forceps,  a  wire  clamp,  a  pair  of 
scissors,  a  number  of  pieces  of  fine  silk,  about  a  foot  long,  for 
ligatures;  a  number  of  pieces  somewhat  thicker,  eighteen  inches 


Fig.  30.— Tait's  Modification  of  Koeberl6's  Forceps. 

long,  for  sutures;  Paquelin's  thermo-cautery,  an  aspirator,  two 
sizes  of  trocar,  and  twelve  good  sponges.  Of  this  list  some  of 
the  items  require  special  mention,  and  the  first  is  the  scissor- 
forceps  of  M.  Koeberle.  Of  the  numerous  minor  improvements 
in  our  method  of  operating,  none  deserves  to  be  spoken  more 
highly  of  than  the  introduction  of  this  instrument.  I  give  above 
a  figure  of  the  pattern  (Fig.  30)  I  use,  though  I  do  not  know  that 
it  has  much  advantage  over  M.  Koeberle's  original  form  beyond 
the  fact  that  it  is  stronger  and  does  not  break,  and  that  its  pointed 
nose  cannot  be  tied  in  the  ligature.  Its  method  of  action  v/ill 
at  once  be  seen.     As  soon  as  a  bleeding  point  is  seen  it  is  seized 


OVARIOTOMY.  259 

by  one  of  these  instruments  and  left  in  its  clutches,  so  that  when 
the  operation  has  advanced  as  far  as  the  treatment  of  the  pedicle 
as  many  as  eight  or  ten  of  these  forceps  may  be  hanging  about 
the  wound.  More  than  twelve  are  rarely  required,  and  if  there 
should  be  need  for  more,  one  or  two  in  use  must  be  released  by 
the  assistant  throwing  a  ligature  round  the  points  held  by  two 
or  three.  I  have  never  more  nor  less  than  twelve,  and  I  have 
them  always  ready  to  my  hand  in  a  small  tray,  covered  with 
water  and  ranged  carefully  in  order  side  by  side,  so  that  at  a 
glance  I  can  tell  how  many  arein  use.  In  this  way  I  make  sure 
that  I  never  leave  one  inside. 

Mr.  Spencer  Wells  gives  a  very  graphic  account  of  an  acci- 
dent of  this  kind  from  his  own  practice,  which  I  quote  in  full  to 
show  how  easily  it  may  occur  in  the  most  experienced  hands  and 
how  constantly  an  operator  must  be  on  the  alert  to  prevent  it : 
'•'  I  took  off,  as  I  thought,  every  pair  of  forceps,  closed  the  wound 
up,  and  everything  seemed  quite  as  it  should  be.  But  about  two 
hours  after  the  operation  I  received  a  message  from  a  friend 
Avho  was  putting  up  the  instruments  for  me  to  say  there  was  a 
pair  of  forceps  missing.  We  knew  exactly  the  number  of  for- 
ceps; if  we  had  not  known  that,  one  pair  would  not  have  been 
missed.  This  shows  how  necessary  it  is  always  to  know  how 
many  forceps  are  taken.  It  was  about  five  in  the  afternoon  when 
I  had  this  message:  'There  is  a  pair  of  forceps  missing;  prob- 
ably they  may  be  in  the  patient.'  Imagine  the  sort  of  feeling 
with  which  one  would  receive  that  intimation.  I  at  once  went 
to  the  patient.  She  seemed  so  well  I  did  not  like  to  disturb  her; 
there  was  some  doubt  where  the  forceps  might  be,  so  I  thought 
I  would  wait  a  little  longer.  I  waited  till  night;  she  still  seemed 
pretty  well,  and  I  thought  I  would  wait  till  the  morning;  but  in 
the  morning  the  nurse  told  me  the  lady  had  been  very  restless. 
I  then  made  a  careful  examination  by  the  vagina  and  rectum 
and  abdominal  wall,  to  see  if  I  could  feel  the  forceps,  but  there 
was  nothing  to  be  felt  at  all.  Still  I  was  uneasy,  and  I  thought 
I  had  better  open  the  wound.  So  I  asked  Mr.  Thornton  to  come 
with  me  and  throw  some  carbolic  spray  over  the  abdomen,  and 
making  some  excuse  to  the  patient,  just  saying  I  thought  it 
necessary  to  change  the  dressing,  and  it  would  be  as  well  that 
she  should  not  feel  it,  I  gave  her  methylene,  removed  the  dress- 
ing, and  took  out  two  stitches.  I  put  one  finger  in,  but  at  first 
could  not  feel  the  forceps.  At  last  I  found  something  hard,  put 
another  finger  in,  and  found  the  forceps  wrapped  up  in  the 
omentum.  From  the  way  in  which  the  omentum  had  insinuated 
itself  into  the  ring-handle  of  the  forceps  and  between  the  blades, 
it  was  easy  to  understand  how  difficult  it  was  to  find  and  re- 


260  DISEASES    OF   THE   OVARIES. 

move  the  instrument ;  but  I  did  it,  returned  the  omentum,  closed 
the  wound,  and  the  patient  was  none  the  worse.  She  got  per- 
fectly well,  and  to  this  day  does  not  know  that  anything  un- 
usual occurred.  Pray  let  me  use  this  confession  to  impress  upon 
you  the  necessity,  not  only  of  counting  sponges,  but  of  counting 
instruments  also,  that  you  may  avoid  any  such  painful  experi- 
ence.'* 

These  instruments  are  of  great  service  in  saving  time,  and 
this  is  a  matter  of  importance  in  an  operation  which  may  extend 
over  an  hour.  When  the  time  comes  for  the  removal  of  the  for- 
ceps, after  the  pedicle  has  been  dealt  with,  it  will  generally  be 
found  that  the  mere  pressure  has  stopped  most  of  the  bleeding 
points.  These  instruments  will  also  be  found  of  great  service  in 
pulling  out  cysts  and  in  many  other  ways  which  experience  will 
indicate. 

The  handled  needles,  armed  with  silk,  are  items  of  the  list 
upon  which  I  take  a  great  deal  of  trouble.  They  must  be  well 
made  and  well  tempered,  so  that  they  will  neither  break  nor 
bend.  They  must  not  have  broad  cutting  points  and  must  not 
make  big  holes.  The  eyes  must  be  perfectly  smooth  and  round, 
so  as  not  to  cut  the  silk.  In  fact,  like  everything  else  in  ovari- 
otomy, they  must  be  perfection.  The  silk  with  which  they  are 
armed  is  of  two  thicknesses,  for  I  always  tie  a  pedicle  or  a  mass 
of  omentum  with  the  thinnest  silk  I  think  capable  of  securing  it. 
Therefore,  for  a  thin  pedicle  I  use  thin  silk,  and  for  a  thick  pedi- 
cle I  use  somewhat  thicker  silk.  The  silk  must  be  pure  Chinese 
twist,  with  no  cotton  in  it,  an  adulteration  easily  detached  by 
liquor  potassse.  I  scald  every  piece  of  silk  to  be  used  before  the 
operation  in  boiling  water,  to  get  rid  of  the  gum,  and  then  I 
stretch  it  tightly  to  test  it  and  to  reset  its  fibres.  In  this  way  I 
have  secured  myself  against  ever  having  had  a  ligature  slip,  an 
accident  I  have  heard  other  surgeons  complain  of. 

The  form  of  trocar  I  use  for  emptying  the  cyst  is  figured  on 
opposite  page,  and  I  claim  for  it  the  advantages  that,  being  per- 
fectly solid,  it  never  admits  air,  and  having  no  inside  mechanism, 
it  never  gets  out  of  order.  The  form  of  its  point  enables  the 
operator  to  puncture  secondary  cysts  without  any  alteration  of 
the  mechanism;  it  is  not  sharp  and  therefore  can  do  no  harm. 

Of  the  sponges  to  be  used  it  is  almost  impossible  to  speak  with 
too  great  emphasis,  as  I  distrust  them  more  than  anything  else 
about  the  operation.  I  never  let  them  out  of  my  sight  and  I  will 
not  permit  any  one  but  the  nurse  in  cliarge  of  them  to  touch 
them.  They  are  prepared  for  each  operation  with  the  utmost 
care  and  the  number  in  use  is  constantly  twelve.  They  are 
counted  before  the  operation,  before  the  wound  is  closed,  and 


OVARIOTOMY. 


261 


again  afterward,  so  that  by  no  possibility  should  one  be  left  in- 
side, an  accident  which  has  happened  a  great  many  times  in  the 
history  of  ovariotomy  and  which  nothing  but  the  greatest  care 
will  prevent  recurring.  Mr.  Spencer  Wells  gives  his  experience 
in  this  point  as  follows: 

''  In  one  case  I  was  a  long  time  searching  for  a  sponge  before 
I  could  find  it.  ISTo  one  who  has  not  tried  would  believe  the  diffi- 
culty of  finding  a  sponge  in  the  abdominal  cavity,  if  it  be  not 
very  large,  and  have  become  saturated  with  fluid.  The  lady 
■was  the  wife  of  a  surgeon,  and  I  operated  upon  her  in  the  fifth 
month  of  pregnancy.  After  the  pedicle  was  secured,  and  I  was 
closing  the  wound,  the  nurse  said  there  was  a  sponge  missing. 
I  said  "  Are  you  quite  sure  ? '  She  counted  again,  and  said,  *  I 
am  sure  there  is  a  sponge  missing.'  I  felt  in  every  direction  in 
this  lady's  abdomen;  put  my  hand  to  the  bottom  of  the  pelvis, 
to  the  front  of  the  uterus,  a,nd  everywhere  I  could  think,  but 


Fig.  31. 


find  the  sponge  I  could  not.  But  at  last,  up  to  the  back  of  the 
liver,  between  the  liver  and  the  diaphragm,  I  found  a  small 
«ponge,  and  removed  it.  The  patient  made  an  excellent  re- 
covery, in  spite  of  all  this  groping.  But  this  leads  me  to  repeat 
the  caution  not  to  use  sponges  so  small  that  they  are  not  easily 
found." 

Let  me  further  say  again  that  no  one  should  touch  the 
sponges  but  the  nurse  responsible  for  them.  In  one  of  my  early 
■operations,  many  years  ago,  a  bystander  hearing  me  ask  for  a 
small  sponge  tore  one  in  two,  so  that  there  were  thirteen  in  use 
instead  of  twelve,  and  both  the  nurse  and  myself  were  ignorant 
of  the  fact.  The  gentleman  who  tore  the  sponge  alone  knew  of 
his  act,  and  he  left  the  room  before  the  operation  was  finished. 
The  result  was  that  we  found  that  thirteenth  sponge  four  days 
after,  and  the  horror  of  the  circumstance  is  as  vividly  in  my 
mind  now  as  if  it  had  happened  yesterday.  I  shall  never  forget 
it  as  long  as  I  live.     I  happen  to  have  heard  of  ten  other  cases 


262  DISEASES   OF   THE   OVARIES. 

in  which  sponges  have  been  left  behind,  so  that  I  need  no  excuse 
for  the  emphasis  of  my  advice  on  this  point. 

The  sponges  used  should  be  of  the  very  best  quality,  should 
vary  somewhat  in  size  and  shape,  and  should  be  perfectly  free 
from  tears  or  ragged  points,  from  which  pieces  may  become  de- 
tached. When  they  are  new  I  soak  them  for  twenty -four  hours 
in  a  solution  of  muriatic  acid  sufficiently  strong  to  be  disagree- 
ably sour  to  the  taste.  This  dissolves  the  particles  of  chalk  with 
which  they  are  infested  and  loosens  the  sand,  and  this  must  be 
completely  washed  out  of  them.  After  each  operation  I  wash 
them  free  from  color  and  then  soak  them  for  forty-eight  hours 
in  a  strong  solution  of  washing-soda  or  ammonia,  to  dissolve  the 
fibrin.  They  are  then  washed  repeatedly  until  the  water  comes 
from  them  perfectly  clean,  and  after  that  they  are  placed  for  a  week 
in  a  five  per  cent,  solution  of  phenol.  Finally,  tliey  are  hung  up 
in  a  well-made  calico  bag  in  a  warm  place  till  they  are  quite 
dry.  I  keep  a  very  large  stock  of  sponges,  and  they  are  a  con- 
stant source  of  anxiety  and  care.  It  is  to  Dr.  Keith  that  we  are 
indebted  for  the  free  and  efficient  sponging  out  of  the  abdomen 
now  always  practised,  and  in  this  respect  he  has  again  largely 
contributed  to  the  advanced  success  of  abdominal  surgery. 

It  hardly  requires  to  be  said  that  the  selection  of  an  anaes- 
thetic is  an  important  matter  for  the  success  of  ovariotomy.  By 
common  consent  the  agent  which  for  so  many  years  held  a  su- 
preme position  in  this  country  has  given  way  to  that  which  was 
first  introduced  for  the  purpose  of  procuring  unconsciousness  to 
pain  in  surgical  operations.  Chloroform,  while  it  acts  with  an 
almost  mathematical  certainty  upon  a  woman  in  labor,  is  a  most 
unsafe  and  uncertain  drug  to  use  in  surgical  operations,  save  in 
the  case  of  a  very  young  child.  It  is  not  only  that  we  have  a 
considerable  number  of  deaths  from  chloroform,  but  that  in  its 
use  we  have  so  much  anxiety  that  the  danger  is  ever  present  in 
the  mind  of  the  operator,  and  this  distraction  is  destructive  of 
that  clear  concentration  which  is  necessary  in  the  performance 
of  ovariotomy. 

Mr.  Spencer  Wells  has  for  a  long  time  advocated  the  use  of 
the  bichloride  of  methylene  by  means  of  Junker's  apparatus,  and 
this  is  certainly  a  very  elegant,  rapid,  and,  compared  with  chloro- 
form, safe  means  of  inducing  ansesthesia.  There  are,  however, 
two  objections  against  its  use;  one  is  that  it  requires  a  special 
apparatus,  and  the  other  that  this  apparatus  requires  some  one 
experienced  in  its  use.  In  the  hands  of  one  who  is  accustomed 
to  give  the  bichloride  I  think  it  is  probably  as  safe  as  any  anaes- 
thetic well  can  be,  but  as  it  is  wholly  impossible  always  to  obtain 
the  services  of  one  sufficiently  skilled,  I  have  for  a  long  time  dis- 


OVARIOTOMY.  26o 

continued  the  use  of  this  agent.  There  are  other  reasons  against 
its  use  which  I  do  not  think  of  sufficient  importance  to  dwell 
upon.  The  agent  I  have  employed  for  the  last  six  years  is  free 
from  any  objection  of  an  important  character.  I  allude,  of  course, 
to  sulphuric  ether,  which  is  now  recognized  as  by  far  the  safest 
ansesthetic  in  use,  the  kind  of  ether  which  I  employ  and  which 
I  prefer  above  all  others  being  the  anhydrous  methylated  ether 
manufactured  by  MacFarlane  &  Co.,  of  Edinburgh,  as  originally 
recommended  by  Dr.  Keith.  The  advantages  of  this  agent  are 
very  numerous.  In  the  first  place,  so  far  as  its  present  use  has 
gone,  it  is  absolutely  safe;  in  my  own  practice  it  has  been  used, 
on  a  rough  estimate,  between  five  and  six  thousand  times,  and 
not  only  have  I  had  no  accident  from  it,  but  its  use  gives  me  no 
anxiety  whatever,  and  whilst  I  am  engaged  in  operating  my 
mind  is  absolutely  at  rest  concerning  the  anaesthetic.'  In  the 
next  place,  it  may  be  administered  by  any  one,  and  when  I  say 
that  in  the  whole  of  my  hospital  practice,  for  nearly  three  years, 
the  ether  has  been  administered  for  all  operations  by  the  sister 
in  charge  or  by  a  nurse,  I  think  I  give  testimony  sufficient  as  to 
my  confidence  in  the  safety  of  the  drug. 

For  its  proper  administration  very  few  rules  need  be  observed 
and  no  kind  of  special  apparatus  is  needed.  It  is  always  given 
for  me  after  the  simple  fashion  which  Sir  James  Simpson  intro- 
duced for  the  administration  of  chloroform,  that  is  by  dropping 
it  on  the  outside  of  a  single  fold  of  a  towel,  laid  upon  the  pa- 
tient's face.  Bearing  in  mind  that  ether  is  extremely  volatile, 
and  that  its  vapor  is  very  heavy,  the  following  directions  must 
be  attended  to.  The  towel  used  must  not  be  too  thin,  because  it 
must  retain  a  sufficient  body  of  ether  for  the  continuance  of  the 
current  of  vapor;  and  yet  it  must  not  be  so  thick  as  to  prevent 
the  passage  of  air  freely  through  it.  The  ether  must  be  dropped 
on  to  the  towel,  not  splashed  on,  but  administered  in  a  continu- 
ous stream,  which  must  be  allowed  to  drop  from  a  small  orifice 
on  to  the  towel,  above  the  level  of  the  patient's  nose,  because  the 
vapor  of  the  ether  will  fall  like  a  cataract  over  the  patient's  face. 
If  the  ether  is  dropped  on  the  towel  on  a  level  with  the  patient's 
mouth,  she  will  inhale,  not  the  vapor,  but  a  mixture  of  air  and 
ether,  which  will  act  as  a  stimulant  and  not  as  an  anaesthetic,  and 
the  ether  must  not  be  splashed  on,  for  exactly  the  same  reason. 
The  towel  should  not  be  tightened  over  the  face,  but  puffed  out 
around  it  at  a  distance  of  an  inch,  or  an  inch  and  a  half,  from 
the  skin,  in  order  that  it  may  enclose  a  body  of  vapor.     The 


'  Since  writing  this  I  have   had  an  accident  (British  Medical  Journal,   July  14, 
1882)  due,  as  I  think,  to  the  use  of  an  inhaler. 


264*  DISEASES   OF   THE   OVARIES. 

whole  of  the  piece  of  towel  covering  the  face  must  be  kept  con- 
tinually moist  with  ether,  and  in  this  way  a  continuous  volume 
of  pure  ether  vapor  will  be  inhaled  by  the  patient.  After  a  few 
minutes  the  part  of  the  towel  in  use  must  be  changed  for  another 
part,  because  anhydrous  ether  absorbs  with  intense  avidity  the 
moisture  of  the  breath,  and  the  towel  will  be  found  coated  with 
ice,  and  this,  by  its  interference  with  rapid  evaporation,  prolongs 
the  process  :  this  is  the  chief  argument  against  all  ether  inhalers. 
Only  one  other  caution  need  be  given,  and  that  is  to  avoid  bring- 
ing any  light  or  red-hot  cautery  near  the  patient's  face  while  the 
ether  is  being  given,  for  it  is  explosive. 

When  these  rules  are  attended  to,  ether  will  be  found  to  be 
the  safest,  quickest,  and  most  satisfactory  of  all  anaesthetic 
agents.  It  has  only  three  objections,  and  these  are  of  but  slight 
importance.  The  first  objection  is  that  the  smell  of  the  ether 
hangs  about  the  clothes  of  tliose  engaged  in  the  operation,  and 
this  is  offensive  to  many  persons;  the  second  is  that  the  quan- 
tity of  ether  used  is  much  larger  than  that  of  any  other  anaes- 
thetic and  therefore  it  is  necessary  to  keep  it  in  large  bulk;  and 
the  third  objection  is  that  the  taste  of  the  ether  is  by  no  means 
so  pleasant  as  either  chloroform  or  methylene;  but  upon  this 
point  I  have  heard  considerable  difference  of  opinion.  The  cost 
of  the  ether  is  less  than  that  of  any  other  anaesthetic  which  I 
have  used. 

During  the  administration  of  ether  there  should  be  absolute 
silence  in  the  room.  No  one  should  be  allowed  to  talk;  more 
particularly,  no  allusion  should  be  made  to  the  patient,  or  to  the 
prospects  of  the  operation,  because  for  a  long  time  after  insensi- 
bility has  apparently  been  reached  ideas  may  be  picked  up  by 
the  patient  from  suggestions  made  at  the  bedside,  and  these 
often  have  a  lasting  and  most  disagreeable  effect.  This  was 
one  of  Simpson's  most  stringent  rules,  and  one  which  never 
ought  to  be  broken.  At  the  beginning  of  the  process  the  quan- 
tity of  ether  should  be  small,  in  order  to  avoid  giving  the  patient 
the  sensation  of  being  suffocated,  because  it  is  at  this  stage  that 
the  state  of  mind  is  induced  which  leads  to  struggling.  Notliing 
makes  any  one  struggle  more  than  the  sense  of  being  choked. 
As  soon  as  it  is  evident  from  the  regularity  of  breathing  that 
the  patient  has  become  accustomed  to  the  presence  of  the  ether 
vapor  in  the  air  the  quantity  given  may  be  increased  to  that 
Avhich  has  been  already  indicated,  and  if  this  condition  be  at- 
tended to  it  will  be  found  that  struggling  will  be  altogether 
avoided,  save  in  the  case  of  children.  When  the  patient  does 
.';truggle,  the  only  thing  to  be  avoided  is  her  getting  hold  of  the 
towel,  and  it  will  generally  be  quite  enough  for  the  nurse  or  as- 


OVAKIOTOMY.  265 

sistant  to  keep  the  hands  quiet  while  the  administrator  of  the 
ether  steadies  the  head.  Whoever  gives  the  ether  should  abso- 
lutely mind  his  or  her  own  business,  and  take  no  interest  what- 
ever in  the  surroundings  during  the  whole  of  the  process;  for 
even  with  an  anaesthetic  so  safe  as  ether  it  is  absolutely  neces- 
sary that  the  whole  attention  should  be  engrossed  with  it. 

Sickness  is  with  ether,  as  with  every  other  anaesthetic,  a 
somewhat  frequent  trouble,  and  indeed  it  is  difficult  to  see  how 
it  can  be  altogether  avoided.  It  is  very  rare,  however,  that  it 
need  be  a  source  of  anxiety;  but  in  one  instance  in  my  practice  it 
was  extremely  serious,  and  the  story  of  the  case  will  give  a  les- 
son more  emphatic,  perhaps,  than  any  mere  directions  which  I 
can  give. 

A  lady  was  placed  under  my  care  some  three  years  ago  for 
the  purpose  of  having  an  ovarian  tumor  removed.  She  was,  as 
usual,  kept  in  bed  for  two  or  three  days  before  the  operation  and 
on  the  morning  of  the  operation  nothing  was  given  to  her  by  her 
attendants,  in  order  that  sickness  might  be  avoided.  The  opera- 
tion was  to  be  performed  at  nine  o'clock,  and  she,  being  pro- 
foundly persuaded  that  upon  an  empty  stomach  she  never  could 
go  through  the  ordeal,  rose  about  six  o'clock  on  the  same  morn- 
ing, went  to  one  of  her  boxes,  which  had  been  unfortunately  left 
in  her  room,  and  in  which  she  had  secreted  a  quantity  of  bis- 
cuits and  a  bottle  of  port  wine,  and  with  these  she  made  a  hearty 
meal.  In  the  middle  of  the  operation  sickness  came  on  and  she 
vomited  a  large  quantity  of  purple  pulp.  She  went  on  inces- 
santly vomiting  for  eight  days,  and  long  before  that  time  I  had 
given  up  all  hopes  of  her  recovery.  The  straining  caused  by  the 
retching  tore  the  wound  open,  and  upon  the  sixth  or  seventh  day 
a  large  sloughy  mass  was  extruded,  which  proved  to  be  the  rec- 
tus muscle  of  the  left  side,  which  had  apparently  been  destroyed 
by  the  continuous  vomiting.  For  ten  days  more  she  lay  with  a 
large,  open  wound,  through  which  could  be  seen  the  movements 
of  the  intestines,  and  between  her  and  another  world,  there  was 
nothing  but  a  layer  of  peritoneum.  Fortunately,  she  did  not 
open  the  wound  any  farther.  She  ultimately  recovered,  and  is 
now  in  perfect  health,  save  that  there  is  a  large  intestinal  protru- 
sion at  the  seat  of  the  wound.  I  do  not  think  that  in  the  whole 
course  of  my  practice  I  have  ever  had  a  case  which  gave  me  so 
nmch  anxiety,  and  it  also  gave  me  a  powerful  argument  by 
which  to  impress  upon  others  the  absolute  necessity  of  obedi- 
ence. 

The  anaesthetic  should,  therefore,  be  always  given  upon  an  ab- 
solutely empty  stomach.  I  do  not  even  approve  of  the  dose  of 
brandy  and  water  usually  given,  because  ether  is  in  itself  one  of 


266  DISEASES   OF  THE   OVAEIES. 

the  most  powerful  stimulants,  and  we  have  only  to  watch  the  im- 
provement upon  a  feeble  pulse  which  takes  place  during  its  ad- 
ministration to  be  quite  satisfied  that  no  other  stimulant  is  neces- 
sary. The  quantity  of  ether  given  during  an  operation,  especially 
during  ovariotomy,  is  necessarily  very  large,  but  no  one  need  ever 
be  alarmed  on  account  of  the  quantity  of  ether  administered.  It 
is  absolutely  necessary  to  keep  all  the  patient's  abdominal  mus- 
cles, except  the  diaphragm,  perfectly  quiet;  and  long  before 
there  is  the  least  danger  the  patient's  deep  snoring  will  indicate 
that  the  stage  of  profound  sleep  has  been  reached.  When  the 
patient  snores  the  administration  should  for  a  short  time  be  dis- 
continued. The  quiet  regularity  of  breathing  which  always 
characterizes  the  unconscious  state  induced  by  breathing  the 
vapor  of  ether  is  quite  enough  to  indicate  to  any  one  of  any  ex- 
perience in  its  use  that  the  patient  is  in  a  condition  of  profound 
insensibility,  and  this  will  also  serve  as  the  best  indication  of 
safety.  There  is,  therefore,  very  little  need  for  the  pulse  being 
watched,  or  for  the  conjunctiva  to  be  experimented  upon  to  de- 
termine unconsciousness.  Should  sickness  come  on  during  the 
operation,  the  ether  should  be  pushed  a  little  more  and  this  will 
stop  it,  because  sickness  really  is  an  indication  of  returning  con- 
sciousness. After  the  operation  is  over,  should  sickness  occur,  it 
is  best  checked  by  the  administration  of  a  little  luke-warm  water 
flavored  with  brandy,  and  without  sugar.  "When  the  patient  is 
sick  she  should  always  be  turned  on  her  side,  as  in  this  position 
the  tongue  falls  forward  and  the  vomit  is  got  easily  rid  of  from 
the  mouth  without  risk  of  its  entering  the  trachea.  Forceps 
should  never  be  used  to  drag  the  tongue  forward,  after  the  bar- 
barous fashion  introduced  by  the  late  Mr.  Syme.  It  is  quite  suf- 
ficient to  turn  the  patient  on  her  side,  or  even  to  turn  the  head 
to  one  side,  if  any  necessity  arises  for  this  during  the  operation. 
Artificial  teeth  should  always  be  removed  from  the  mouth  before 
the  ether  is  given. 

There  is  only  one  risk  about  the  administration  of  ether,  and 
that  is  the  occurrence  of  bronchitis  in  old  people.  I  have  not 
seen  this  often,  but  in  several  instances  I  have  had  reason  for 
anxiety  on  this  ground,  and  in  order  to  avoid  this  risk  I  have 
devised  an  apparatus  by  which  the  vapor  of  ether  is  given  at  a 
temperature  of  33°  Centigrade,  that  is,  very  nearly  its  boiling- 
point. 

The  woodcut  on  opposite  page  will  explain  the  apparatus 
which  I  have  devised  for  the  purpose.  Anhydrous  methylated 
ether  (.720)  is  placed  in  the  reservoir.  A,  which  will  hold  about  ten 
ounces,  and  which  is  furnished  with  a  spring  pump,  which  drives 
over  about  a  dram  of  ether  at  each  stroke  into  the  glass  boiler,  B. 


OVARIOTOMT. 


267 


This  boiler  is  suspended  in  a  hot-water  tank,  C,  beneath  which 
is  a  spirit-lamp.  From  the  boiler  an  exit  tube,  four  or  five  feet 
long,  passes  to  a  Junker's  mouth-piece. 

When  the  apparatus  is  to  be  used,  the  tank  is  filled  with 
water,  the  spirit-lamp  is  lighted,  and  about  three  drams  of  ether 
is  pumped  into  the  boiler.  Care  must  be  taken  that  there  is  no 
leakage  from  the  boiler,  otherwise  there  will  be  an  ignition.  It 
will  soon  be  found  that  the  boiling  ether  gives  over  a  large  vol- 
ume of  vapor  at  a  constant  temperature  of  a  few  degrees  below 
the  boiling-point  of  the  sample,  which  of  course  will  vary  very 
much,  but  will  generally  be  found  to  be  pretty  nearly  the  tem- 
perature of  expired  air,  31°— 33°  Cels.     When  given  at  this  tern- 


Fig.  32. — Appai-atus?  for  the  Administration  of  Ether-vapor  at  Blood-heat  in  Cases  of  Old  People. 

perature,  and  free  from  air,  the  vapor  is  quite  pleasant,  and  its 
taste  or  rather  its  comparative  freedom  from  taste,  reminded  me 
•when  I  tried  it  on  myself,  greatly  of  the  flavor  of  nitrous  oxide. 
It  is,  of  course,  certain  that  its  administration  will  involve  no 
risk  of  bronchitis. 

I  think  this  method  will  be  found  to  be  a  substantial  advance 
in  the  method  of  ether  administration  for  old  people;  and  if  care 
be  taken  to  keep  the  boiler  vapor-tight,  and  the  mouth-piece 
three  or  four  feet  away  from  the  spirit  flame,  I  think  the  appara- 
tus will  be  found  quite  safe.  Dr.  Lauder  Brunton  made  to  me 
the  ingenious  suggestion  of  having  a  steam-jacket  round  the 
boiler,  but  that  I  have  not  found  to  be  practicable  without  greatly 


268  DISEASES   OF   THE   OVARIES. 

complicating  the  apparatus.  The  use  of  a  hot  iron  bolt  to  boil  the 
water,  instead  of  the  lamp,  would  probably  be  safer,  but  it  would 
not  be  so  handy,  and  would  involve  great  wear  and  tear. 

There  comes  in  now  the  question  of  the  adoption  of  what  are 
called  antiseptic  ijrecautions,  and  of  these  it  is  quite  impossible 
to  speak  without  a  discussion,  however  brief,  of  the  theory  upon 
which  they  are  based.  This  is  necessary  for  many  reasons,  but 
chiefly  because  the  followers  of  the  antiseptic  doctrine  assert, 
with  a  vehemence  worthy  of  the  scholastics  of  the  fifteenth  cen- 
tury, that  unless  there  be  faith  in  the  doctrine  there  can  be  no 
success  in  the  practice. 

To  those  who  have  followed  closely  the  elaborate  researches 
upon  the  phenomena  of  putrefaction,  which  have  occupied  some 
of  the  greatest  minds  of  our  time  during  the  last  fifteen  years,  it 
must,  I  think,  be  admitted  as  an  established  fact  that  these 
phenomena  arise  from  the  presence  of  minute  living  organisms 
in  the  air,  which  can  be  removed  from  it  by  a  variety  of  physical 
means,  by  which  the  air  is  rendered  absolutely  harmless  to  the 
substances  which  are  experimented  upon.  Further,  that  so  far 
as  we  know,  no  phenomena  of  putrefaction  do  occur  without  the 
admission  of  these  so-called  germs  to  the  substance  putrefying, 
that  the  putrefactive  processes  depend  entirely  upon  them  and 
the  organisms  to  which  they  give  rise,  and  that  the  origin  of 
such  organisms  within  the  putrefying  fluid,  independently  of  a 
sowing  of  seed  in  the  fluid,  though  by  no  means  to  be  regarded 
as  an  impossibility,  is  not  yet  proved  as  an  actual  occurrence. 
To  any  who  takes  a  general  view  of  the  biological  scheme  from 
the  aspect  of  the  evolutionary  philosophy  I  think  it  must  be 
clear  that  the  so-called  ''spontaneous"  generation  of  the  early 
forms  of  life  is  a  necessary  corollar}^  but  it  is  by  no  means  cer- 
tain that  it  is  a  part  of  the  present  process,  nor  is  it  likely,  in  my 
opinion,  that  we  now  have  upon  the  earth  such  conditions  as 
would  render  biogenesis  possible. 

For  my  present  purpose,  therefore,  it  is  enough  for  me  to  as- 
sume, as  I  do  most  fully,  that  the  germ  theory  has  been  com- 
pletely substantiated,  and  that  no  known  process  of  putrefaction 
does  occur  save  by  the  admission  of  resting  spores  or  swarm 
spores  of  some  of  the  many  minute  living  organisms  which  are 
invariably  associated  with  putrefactive  changes.  But  concern- 
ing this  there  is  another  constant  position  associated  with  these 
phenomena.  The  materials  upon  which  the  experiments  have 
been  made,  of  infinite  variety  of  kind  and  constitution,  have  all 
been  dead,  and  no  one  has  yet  pretended  that,  by  the  admission 
of  germs  to  living  matter,  he  has  produced  tlie  phenomena  of  the 
putrefactive  changes  which  constantly  result  in  matter  which  is 


OVATIIOTOMY.  269' 

dead.  To  quote  the  apt  illustration  given  by  Dr.  Wm.  Roberts 
in  his  masterly  exposition  of  this  most  difficult  subject,  the  ordi- 
nary hypodermic  morphia  syringe  will  inoculate  inevitably  a 
sterilized  solution  of  dead  organic  matter,  but  amongst  the  hun- 
dreds and  thousands  of  hypodermic  injections  which  are  made 
daily,  no  one  has  yet  declared  a  single  instance  of  putrefactive 
changes  resulting  from  it  in  the  healthy,  or  even  in  the  diseased 
human  body. 

It  will,  therefore,  be  seen  that  the  application  of  the  facts  of 
the  germ  theory  of  putrefaction  to  the  phenomena  of  diseases  of 
living  tissue  is  met  at  once  by  an  overwhelming  difficulty,  to  the 
removal  of  which  none  of  the  adapters,  so  far  as  I  have  seen, 
have  as  yet  applied  themselves.  Granting  that  the  same  germs 
which  would  inevitably  produce  putrefaction  in  a  dead  infusion 
of  beef  are  constantly  admitted  to  wounds,  there  is  not  the 
slightest  particle  of  evidence  that  they  do  produce  any  change 
whatever  upon  living  tissue,  still  less  is  there  any  evidence  that 
the  changes  which  occur  in  the  numerous  varieties  of  what  we 
call  blood-poisonings,  even  when  they  are  of  an  undoubtedly 
local  origin,  have  the  slightest  analogy  to  those  seen  in  a  putre- 
fying dead  infusion.  The  mere  presence  of  bacteria  in  the  fluids 
of  wounds,  or  in  fluids  enclosed  in  cavities,  whilst  offering  many 
difficulties  to  the  adapters  of  the  germ  theory,  prove  nothing  for 
their  position  until  they  have  shown  that  these  organisms  ever 
do  occur  in  fluids  or  tissues  which  are  truly  living. 

The  difficulty,  therefore,  is  this,  that  what  we  call  vital  action, 
for  want  of  a  name  based  upon  a  better  understanding  of  what 
it  is,  places  living  tissue  in  an  altogether  different  category  from 
tissue  in  which  the  phenomena  of  life  are  no  longer  present. 

Now,  this  is  consonant  with  e very-day  experience.  If  a  de- 
caying hyacinth  bulb  or  a  rotting  apple  be  examined,  the  pre- 
sence of  the  minute  forms  of  life  is  found  to  be  absolutely  con- 
fined to  those  parts  where  the  changes  have  been  effected,  whilst 
those  parts  to  which  the  rot  has  not  extended  are  found  abso- 
lutely free  from  them,  and  the  difficulty  of  the  adaptation  of  the 
germ  theory  is  simply  this,  that  its  advocates  have  assumed  that 
the  invasion  of  the  germs  is  the  cause  of  the  decadence  of  the 
vital  phenomena  and  the  ultimate  death,  while  there  is  the  al- 
ternative— still  undiscussed  and  certainly  undismissed — that  the 
decadence  of  the  vital  powers,  due  to  some  cause  possibly  yet 
unknown,  is  that  which  gives  the  germs  their  potential  ascend- 
ancy, and  enables  them  to  do  what,  during  full  vital  action,  they 
were  wholly  unable  to  effect. 

If  the  views  of  the  germ  theorists  were  correct,  we  ought  to 
expect  that  no  operation  could  be  done  successfully  without  rigid 


270  DISEASES   OF   THE   OVARIES. 

antiseptic  precautions.  The  slightest  cut  of  the  skin  ought  to 
be  followed  by  septic  poisoning.  There  ought  to  be  no  differ- 
ence in  the  mortality  of  operations  in  small  and  in  large  hospi- 
tals, in  town  and  in  country.  In  fact,  if  germs  could  have  had 
the  unbounded  influence  which  is  claimed  for  them  by  many  an- 
tisepticists,  surgery  must  long  ago  have  been  an  extinct  art,  if, 
indeed,  it  ever  could  have  struggled  into  existence. 

The  uniform  experience  of  operating  surgeons  has  taught 
them  that  the  success  of  their  work  will  depend  upon  three  fac- 
tors, the  condition  of  the  patient,  the  condition  of  his  surround- 
ings, and  the  nature  and  extent  of  the  operation  performed. 

Of  these  three,  undoubtedly  the  most  uncertain  factor  is  the 
first.  What  condition  of  the  system  it  is  which  is  favorable 
to  operations  is  almost  unknown.  I  must  base  my  conclusions 
chiefly  upon  my  own  work,  and  in  my  special  operation  of 
ovariotomy  I  am  perfectly  certain  that  apparent  perfect  health 
is  by  no  means  a  certain  indication  of  a  power  of  resistance  to 
those  conditions,  whatever  they  be,  which  result  in  so-called 
septic  poisoning. 

The  second  of  the  factors,  the  condition  of  the  surroundings 
of  the  patient,  contains  elements  of  far  greater  certainty.  It 
has  approached  the  position  of  a  statistical  law  that  the  death- 
rate  is  in  constant  harmony  with  the  density  of  the  population, 
and  that  v/hen  the  density  exceeds  a  certain  minimum  of  safety 
there  are  introduced  specific  septic  diseases,  as  typhus  fever, 
which  are  wholly  unknown  under  other  conditions,  and  which, 
even  after  the  danger  density  has  been  reached,  attack  certain 
individuals  only,  and  not  all,  for  reasons  which  can  be  expressed 
only  by  saying,  as  I  have  already  said,  that  the  living  tissues  of 
those  affected  could  not,  and  did  not,  resist  the  septic  influence. 

Every  advance  we  make  in  sanitation  shows  that  this  factor, 
the  condition  of  the  surroundings  of  the  patient,  is  of  extreme 
importance. 

The  third  factor  which  influences  surgical  success  is  the  ex- 
tent and  importance  of  the  operation  performed.  Everybody 
knows  that  while  amputation  of  a  finger  is  probably  fatal  in  not 
more  than  one  in  ten  thousand  cases,  nearly  one-half  of  all  am- 
putations of  the  thigh  die.  Now,  if  the  adaptation  of  the  germ 
theory  to  surgical  practice  were  as  promising  and  as  legitimate  as 
some  of  its  supporters  allege,  we  should  have  had  the  remarkable 
result,  previous  to  its  application,  that  amputations  of  the  fin- 
ger and  of  the  thigh  ought  to  have  approached  one  another  in 
mortality  to  an  infinitely  larger  extent  than  they  have  done. 

If  the  contact  of  a  bacterium  germ  upon  a  wound  could  be 
the  source  of  blood-poisoning,  then  the  size  of  the  wound  and 


OVAKIOTOMY.  271 

the  nature  of  the  operation  could  make  but  small  difference  in 
the  result,  and  a  wound  into  the  theca  of  a  finger  tendon,  and 
one  of  similar  size  into  the  peritoneum  of  another  patient  in 
the  same  ward,  ought  to  have  very  similar  risks.  But,  as  a 
matter  of  fact,  they  do  not,  and  we  are  forced  to  the  conclusion 
that,  even  if  bacterium  germs  lighting  on  wounds  are  the 
cause  of  much  surgical  mortality,  that  the  power  of  vital  resist- 
ance by  the  tissues,  or  the  condition  of  the  patient,  and  the  ex- 
tent and  nature  of  the  operation,  are  of  infinitely  greater  impor- 
tance as  factors  in  the  general  result.  This  logical  difficulty  has 
evidently  occurred  to  many  of  those  who  carry  out  Mr.  Lister's 
adaptation  of  the  germ  theory  to  surgical  practice.  I  have  seen 
a  rigid  antisepticist  occupy  an  hour  and  twenty  minutes  in  mak- 
ing incisions  a  fraction  of  an  inch  in  measurement,  and  barely 
skin  deep,  for  the  purpose  of  laying  bare  the  tympanic  mem- 
branes of  an  infant  in  whom  they  had  been  congenitally  cov- 
ered, the  protraction  of  the  operation  being  due  solely  to  the 
antiseptic  precautions.  Such  a  proceeding  produced  in  my  mind 
a  variety  of  emotions,  chief  of  which  were  admiration  for  the 
enthusiastic  consistency  of  the  operator  and  sympathy  for  his 
evidently  wearied  audience.  The  just  criticism  of  such  a  pro- 
ceeding is  the  question,  -'Has  any  one  ever  seen  such  a  trivial 
operation  result  fatally  from  septic  poisoning,  unless  in  some 
such  hospital,  as  is  described  by  John  Howard  in  1780,  as  the 
Hotel  Dieu,  with  three  patients  in  each  bed  ? "  I  certainly 
never  have,  and  I  have  performed  some  thousands  of  them ;  and 
if  it  were  necessary  to  take  one  hundred  minutes  to  do  what  I 
could  do  in  three  I,  for  one,  should  seek  my  livelihood  in  some 
employment  other  than  that  of  an  operating  surgeon. 

The  logical  conclusion  to  be  drawn  from  the  facts  is,  therefore, 
that  in  minor  operations  germs  have  never,  or  at  least  hardly 
ever,  any  influence  at  all,  and  that  in  major  operations  the  con- 
dition of  the  patient  is  of  immense  importance  in  enabling  him 
to  resist  the  influences,  whatever  they  may  be,  which  result  in 
what  we  call  the  septic  condition. 

In  any  examination  of  the  question  there  will  of  course  be  the 
primary  difficulty,  that  it  is  by  no  means  agreed  as  to  what  con- 
stitutes a  major  operation,  and  that  between  different  operations 
which  are  admitted  as  major,  there  are  known  to  be  very  different 
rates  of  mortality.  Thus,  amputation  of  the  leg  is  proved,  in 
my  book  on  "  Hospital  Mortality,"  to  be  more  than  twice  as  fatal 
when  performed  for  accident  as  when  performed  for  disease.  It 
must  be  perfectly  evident,  therefore,  that  any  examination  of 
this  question  must  be  conducted  upon  the  usual  rules  of  statistical 
investigation,  the  chief  of  which  is  that  similar  and  not  dis- 


272  DISEASES    OF   THE   OVAllIES. 

similar  accidents  should  be  grouped  together.  Any  mere  state- 
ment, therefore,  of  the  general  percentage  of  deaths  from  septic 
diseases  on  the  general  hospital  or  other  population  are  abso- 
lutely worthless  unless  they  be  most  carefully  analyzed,  and  they 
are,  of  course,  open  to  the  still  further  objection  that  what  con- 
stitutes a  death  from  septic  disease  is  by  no  means  a  perfectly 
accepted  definition. 

There  is  a  popular  belief  that  statistics  can  be  made  to  prove 
anything,  than  which  there  is  no  popular  belief  more  erroneous. 
Statistics  alone  seldom  prove  anything,  certainly  they  never  ex- 
plain anything.  Thus,  the  Registrar-General's  tables  tell  us 
that  there  are  certain  death  quantities  which  are  perfectly  con- 
stant, and  they  establish  the  fact  that  half  of  all  our  human 
mortality  occurs  before  the  fifth  year  of  life.  But  this  neither 
proves  nor  explains  the  cause  of  this  mortalit}'^,  nor  does  it  even 
explain  its  factors,  until  a  more  careful  analysis  of  individual 
cases  is  made.  Therefore,  nothing  whatever  can  be  proved  for 
or  against  the  adaptation  of  the  germ  theory  to  surgical  practice 
by  mere  statistical  statements.  But  in  spite  of  this,  statistics 
may  be  made  to  show  exactly  in  what  direction  analysis  of  indi- 
vidual instances  should  be  made,  and,  therefore,  they  alone  are 
capable  of  forming  the  first  step  of  accurate  inquiry.  First,  let 
us  ascertain,  as  fully  as  possible,  what  the  facts  are,  and  then 
analytical  arrangements  of  them  will  certainly  afford  a  more  or 
less  complete  explanation  of  their  method  of  production. 

Thus,  it  must  be  evident  to  every  one  that  a  large  group  of 
one  hundred  ovariotomies  must  present  features  more  similar  to 
those  of  another  set  of  a  hundred  than  can  probably  be  got  in 
any  other  surgical  comparison  which  is  possible ;  and  it  is  a 
probably  correct  assumption  that  if  the  same  surgical  skill  and 
patience,  the  same  attention  to  minute  details,  and  the  same 
state  of  the  surroundings  were  common  to  the  two  groups,  their 
resulting  mortality  would  be  identical  or  nearly  so.  But  if  there 
is  one  thing  we  value  more  than  another,  as  being  likely  to  con- 
tribute to  success  in  surgical  operations,  it  is  personal  experi- 
ence ;  and  we,  therefore,  may  fairly  expect  that  with  each  suc- 
ceeding hundred  ovariotomies  the  mortality  will  diminish,  owing 
to  the  increasing  skill  of  the  operator.  And  this  is  the  case  not- 
ably in  the  practice  of  Dr.  Keith,  who,  beginning  with  eleven 
per  cent.,  went  successively  down  to  eight  and  six  before  he  be- 
gan to  use  antiseptics  ;  and  of  my  own  experience  I  can  only  say 
that,  while  I  had  nineteen  deaths  in  my  first  fifty  operations,  I 
had  only  three  in  my  second  fifty,  and  in  all  my  subsequent 
practice  these  good  results  have  been  fully  maintained  ;  indeed, 
have  been  excelled. 


OVARIOTOMY.  273 

A  recovery  after  an  ovariotomy  is  the  sum  of  a  number  of 
details,  all  of  which  were  efficient.  A  death,  on  the  contrary, 
may  be  the  failure  of  one  only,  and  that  may  be  or  may  not  be 
under  the  control  of  the  surgeon.  Thus,  of  the  three  fatal  cases 
in  my  second  fifty,  two  were  deaths  due  to  details  wholly  beyond 
my  control,  and  having  no  relation  whatever  to  either  the  anti- 
septic system  or  any  other  of  the  operative  details.  The  third 
death  was  due,  as  far  as  I  could  determine,  to  the  irritative  effects 
of  thymol,  used  with  full  antiseptic  details.  Two  of  these  deaths 
were  antiseptic  out  of  twenty-nine  cases  treated  antiseptically  ; 
while  of  twenty-one  cases  treated  without  antiseptic  precau- 
tions, I  had  only  one  death,  and  as  the  patient  died  within  three 
hours  after  the  operation,  the  want  of  antiseptic  precautions 
could  have  had  nothing  to  do  with  her  death.  From  this  group  of 
cases,  therefore,  the  argument  would  be  wholly  against  the  anti- 
septic system,  and  though  my  impression  is  that  the  conclusion 
would  be  a  just  one,  yet  the  argument  is  absolutely  fallacious, 
as  all  such  are. 

In  the  discussion  of  this  question,  which  occurred  some 
months  ago,  the  only  statistical  argument  of  the  slightest  impor- 
tance was  given  by  Mr.  Spencer  Wells,  who  said  that  a  very 
marked  improvement  had  occurred  in  his  results  since  he  had 
used  antiseptic  precautions.  But  nearly  concurrently  with  his 
adoption  of  germicides,  he  adopted  the  intra-peritoneal  method 
of  dealing  with  the  pedicle,  a  method  which  has  been  superla- 
tively successful  in  the  hands  of  Dr.  Keith,  and  to  which,  chiefly, 
I  attribute  my  own  rapidly  increasing  success.  Thus,  Mr.  Wells' 
mortality  improvement  argues  nothing  in  favor  of  antiseptics,, 
but  far  more,  in  my  opinion,  for  the  short  ligature. 

The  greater  part  of  what  I  have  just  said  upon  this  most  inter- 
esting and  important  subject,  is  taken  from  a  paper  which  I  read 
before  the  Royal  Medical  and  Chirurgical  Society  of  London,  in 
February,  1880,  and  which  is  published  in  vol.  Ixiii,  of  the  ''  Trans- 
actions," and  its  general  conclusions  are  quite  in  harmony  with 
the  opinion  expressed  by  Mr.  Spencer  Wells,  in  his  lectures  de- 
livered before  the  Royal  College  of  Surgeons.  I  give  his  opinions 
as  they  are  reported  in  the  medical  journals  at  length,  for  they 
are  very  important.  He  says:  ''If  (say  the  supporters  of  Lis- 
terism)  in  one  of  the  most  serious  operations  ever  performed 
upon  the  human  body,  where  the  largest  serous  cavity  is  opened 
and  the  freest  access  is  afforded  to  any  infective  organisms 
which  may  be  near  the  patient,  Mr.  Wells  can  obtain  eighty  re- 
coveries out  of  one  hundred  operations  ;  and  as  on  two  occasions 
he  has  had  long  series  of  successful  cases — one  of  twenty  and  two 
of  twenty-seven — without  a  death  to  break  the  run  of  success  : 
18 


274  DISEASES   OF   THE    OVARIES. 

if  in  the  last  two  years  of  his  practice  at  the  Samaritan  Hospital, 
in  1876  and  1877,  he  had  only  seven  deaths  out  of  seventy-one 
cases — not  one  in  ten — and  all  this  without  any  of  the  special  pre- 
cautions supposed  to  be  necessary  by  the  advocates  of  the  antisep- 
tic system — never  using  the  spray  nor  any  carbolized  solutions  for 
sponges  or  instruments,  no  catgut  sutures,  and  no  protective  car- 
bolized gauze  for  dressing  ;  if  such  results  as  these,  in  such  an 
operation,  have  been  obtained,  is  it  possible  that  the  germ  theory 
can  be  true  or  the  practice  founded  upon  it  necessary?  It  is 
troublesome ;  may  it  not  be  injurious  ?  Cases  of  poisoning  by 
carbolic  acid — fatal  poisoning — have  been  recorded,  and,  in  many 
cases  where  recovery  has  followed,  the  patients  have  been  ex- 
posed to  great  suffering  and  inconvenience." 

"  They  claim  the  successes  as  proofs  of  the  value  of  the  [anti- 
septic] system  ;  they  explain  the  failures  by  some  alleged  neglect 
of  some  petty  detail.  In  one  case  I  thoughtlessly  used  a  clamp 
which  had  not  been  carbolized,  and  was  warned  of  probable  fail- 
ure ;  but  the  case  appears,  in  spite  of  my  negligence,  on  the  list 
of  successful  antiseptic  operations,  and  was  one  of  the  cases  in 
which  there  was  no  fever  after  the  operation.  If  there  had  been 
any  fever,  no  doubt  it  would  have  been  explained  to  the  entire 
satisfaction  of  many  people  by  the  presence  of  some  infective 
germs  on  the  clamp.  Of  course,  this  explanation  might  possibly 
be  true  ;  and  I  freely  admit  that,  in  an  experimental  inquiry,  no 
such  carelessness  should  be  permitted,  especiall}''  as  it  gives  rise 
to  the  suggestion,  from  zealous  or  enthusiastic  partisans,  that  no 
one  but  themselves  can  be  safely  trusted  to  perform  an  operation 
antiseptically.  '*  If,"  they  say,  "you  do  not  believe  in  the  pres- 
ence and  omnipotence  of  germs — infective  germs — all  about  the 
patient  and  surgeon,  nurses,  bedding,  instruments,  sponges, 
dressings— indeed,  always  and  everywhere — you  will  be  sure  to 
leave  some  loophole  unprotected  against  the  entrance  of  one  or 
more  of  these  dreaded  enemies.  You  must  accept  the  theory,  or 
act  as  if  you  did,  or  your  practice  will  certainly  be  faulty."  My 
answer  to  this  would  be  that  I  have  watched  the  performance  of 
a  good  many  operations  by  surgeons  who  have  complete  faith  in 
the  system,  and  who  believe  they  carry  it  out  accurately,  but  I 
have  never  yet  seen  one  case  where  a  good  many  germs  might 
not  have  escaped  the  action  of  the  carbolic  acid  ;  and  I  believe 
that  I  or  any  surgeon  present  who  wishes  conscientiously  to 
protect  his  patient  from  any  of  the  atmospheric  or  other  im- 
purities which  may  possibly  affect  her  injuriously,  whether 
he  uses  carbolic  acid  or  any  other  antiseptic,  may,  by  careful 
attention,  do  so  as  completely  and  thoroughly  as  the  most  ac- 
<Mirate  experimenter  can  desire.     Feeling  all  this,  and  feeling, 


OVARIOTOMY.  275 

also,  that  undue  faith  in  the  system  may  lead  to  rash  practice 
and  the  attempt  to  do  things  which  had  better  be  left  alone,  and 
knowing,  also,  how  difficult  it  is  to  obtain  any  trustworthy,  statis- 
tical, comparative  facts  to  determine  the  relative  success  of  any 
operation  well  performed,  with  and  without  antiseptic  precau- 
tions— all  other  things  being  equal — I  think  what  I  have  said  of 
my  own  observations,  altliough  they  only  amount  to  twenty-two 
cases,  may  have  some  little  value."'  What  Mr.  Wells  complains 
of  here  is,  I  think,  a  very  just  object  of  criticism.  The  argument 
of  many  of  the  supporters  of  Mr.  Lister's  theories,  and  the  pro- 
mulgators of  his  practice,  use  an  argument  very  like  the  school- 
boy catch,  "Heads  you  lose,  tails  I  win."  If  there  is  success, 
then  it  is  Listerism;  if  there  is  failure,  then  it  is  not  Listerism; 
some  important  detail,  like  Mr.  Wells'  clamp,  has  been  improp- 
erly managed,  and  the  failure  is  no  fault  of  the  system. 
Another  method  of  their  argument  is  to  say  that  their  opponents, 
having  no  faith  in  the  system,  can  have  neither  honesty  nor  in- 
telligence sufficient  to  carry  it  out.  To  such  a  method  of  discus- 
sion it  is  impossible  to  reply  with  courtesy;  and  my  only  answer 
is  that,  as  it  is  my  best  interest  to  cure  my  patient,  I  am  ready 
and,  I  believe,  capable  of  applying  any  practice  for  that  pur- 
pose, but  that  I  do  not  care  willingly  to  approach  the  land  of 
quackery. 

Since  Mr.  Wells  delivered  his  lectures  he  has  seen  reason  to 
change  his  opinions,  and  he  now  attributes  his  diminished  mor- 
tality to  the  introduction  of  antiseptics.  There  is  this  difficulty, 
however,  left  for  him  to  explain  :  his  mortality  now  is  double 
that  which  Dr.  Keith  had  secured  before  he  used  antiseptics  at 
all,  and  at  a  time  when  Dr.  Keith's  experience  was  little  more 
than  a  fifth  of  what  Mr.  Wells'  is  at  present. 

I  think  it  very  likely  that  if  my  own  results  with  the  Listerian 
details  had  been  bad,  it  would  have  been  said  that  I  did  not 
understand  the  system,  and  never  could,  and  I  think  the  charge, 
probably,  would  have  been  correct.  But  my  results  were  good, 
and  therefore  they  were  allowed  to  pass.  But  I  really  believe 
that  very  few  of  my  cases  would  have  been  admitted  by  an 
enthusiastic  Listerian,  and  I  am  quite  sure  that  for  the  last  two 
years  not  a  single  case  would  have  passed  muster.  Whether  or 
not  that  be  so,  here  are  the  results  of  the  whole  of  my  practice 
up  to  the  date  of  my  writing  this  : 

Per  cent.  Mortality, 

Ligature,  non-antiseptic  ( 1 87  cases) 3.74 

Ligature,  antiseptic  (52  cases) 3.84 

Clamps,  non-antiseptic  (30  cases) 25.00 

Clamps,  antiseptic  (26  cases) 27.00 


276  DISEASES   OF   THE   OVARIES. 

Can  any  reasonable  being  doubt  that  here  the  improvement 
lies  in  the  giving  up  of  the  clamp?  In  the  figures  for  the  ''  anti- 
septic ligature "  I  give  credit  for  twenty-two  consecutive  re- 
coveries in  which  Listerism  was  not  really  complete,  as  Mr. 
Lister's  dressings  were  never  used,  nothing  but  plain  dry  cotton 
wool  being  put  upon  the  wounds,  and  if  the  results  had  been 
bad  among  these,  my  Listerism  would  be  scouted.  If  I  put 
these  cases  to  the  credit  of  •'  non-antiseptic  ligature,"  as  I  very 
fairly  might,  then  the  account  would  stand  thus  : 

Per  cent.  Mortality. 

Non-antiseptic  ligature  (209  cases) 3.00 

Antiseptic  ligature  (30  cases) 6.6 

Thus  it  is  that  I  am  very  hard  of  belief  about  the  merits  of 
the  Listerian  details  as  applied  to  ovariotomy,  the  more  so  as  I 
have  carried  out  all  the  processes  with  plain  cold  water,  and  got 
quite  good  results,  and  I  find  that  the  chief  advocates  of  the 
"antiseptic  system,"  those  who  attribute  their  success  to  it,  never 
get  their  mortality  lower  than  ten  or  twelve  per  cent.,  whereas 
without  it  I  keep  under  five  per  cent.  I  can  regard  this  sudden 
love  for  the  antiseptic  system  as  nothing  but  a  shield  to  cover 
the  retreat  from  the  use  of  the  clamp. 

Mr.  Spencer  Wells*  last  utterances  on  the  question  of  Lister- 
ism are  very  important.  In  his  recently  published  work  on 
''Ovarian  and  Uterine  Tumours"  he  says:  "Four  of  my  last 
sixteen  deaths  were  caused  by  septicaemia,  so  that  antisepticism 
has  not  abolished  this  plague  of  abdominal  surgery.  Lister  s 
antiseptic  plans  have  not  brought  me  to  the  point  of  seeing  no 
deaths  from  septicaemia,  as  promised  by  some  of  their  enthusi- 
astic promoters,  nor  have  they  advanced  my  success  in  operating 
beyond  what  was  obtained  without  it."  These  words  seem  to 
me  to  contain  a  practical  and  complete  admission  of  what  I  have 
always  contended,  that  Mr.  Wells'  greater  success  was  due  to 
his  giving  up  the  clamp.  The  mortality  of  his  first  800  cases  was 
25.5  per  cent.,  while  in  the  subsequent  200  it  was  only  14.5. 

My  views  received  very  valuable  support  from  Dr.  Granville 
Bantock,  Senior  Surgeon  to  the  London  Samaritan  Hospital,  in 
a  letter  he  published  in  the  British  Medical  Journal  for  January 
8,  1881,  from  which  I  take  the  following  extract : 

"I  quite  concur  with  Mr.  Lawson  Tait,  when  he  says  that 
'  the  method  of  recovery '  is  of  far  more  value  in  estimating  the 
merits  of  any  particular  system  than  '  the  mere  death-rate,' 
which  is  often  a  matter  of  luck,  and  especially  when  the  difrer- 
ence  in  the  latter  is  measured  by  units,  I  further  agree  with 
him  in  attributing  to  the  present  mode  of  treating  the  pedicle 


OVARIOTOMY.  277 

much  of  the  success  which  has  recently  been  achieved.  If  there 
is  one  thing  more  than  another,  in  the  matter  of  ovariotomy,  to 
which  I  look  back  with  satisfaction,  it  is  to  the  persistency  with 
which  I  held  to  and  urged  the  systematic  use  of  the  ligature  at 
a  time  when  (in  ib75),  owing  to  the  powerful  and  sustained 
advocacy  of  Mr.  Spencer  Wells,  the  clamp  was  at  the  zenith  of 
its  fame.  Notwithstanding  the  excellent  results  obtained  by 
Dr.  Tjder  Smith,  the  ligature  had  fallen  into  unmerited  obliv- 
ion, and  was  at  that  time  used  only  as  a  dernier  ressort,  and  in 
the  most  desperate  cases.  Thus,  Mr.  Wells  says  (at  page  30 1  of 
his  book),  •  you  will  hardly  wonder  that  I  use  the  clamp  when- 
ever I  can ; '  and  at  page  371,  he  says,  '  the  more  I  see  of  ovario- 
tomy ....  and  the  more  I  am  driven  to  resort  to  cautery 
or  ligature,  the  less  I  am  satisfied  with  the  results  of  these 
methods,  the  more  reluctant  am  I  to  employ  them,  and  the 
greater  is  my  confidence  in  the  clamp,'  etc.  The  evidence  I 
produced  in  favor  of  the  ligature,  as  far  back  as  1872,  before  the 
Obstetrical  Society,  appears  to  have  missed  that  notice  which  is 
claimed,  and  which  subsequent  events  have  shown  it  to  have 
deserved." 

Dr.  Keith,  in  the  record  of  his  cases,  does  not  give  completely 
such  details  as  afford  a  perfect  statement  of  his  results,  based 
upon  the  various  methods  of  treating  the  pedicle  ;  but  he  tells  us 
that  in  his  first  50  cases  he  used  the  clamp  48  times,  with  9 
deaths.  In  his  second  50  he  merely  indicates  that  his  confidence 
in  the  cautery  is  returning.  In  his  third  50,  the  clamp  was  used 
34  times,  with  7  deaths,  and  the  cautery  and  short  ligature  15 
times,  without  a  death  ;  and  now  I  understand  from  himself  that 
he  has  entirely  abandoned  the  extra-peritoneal  method  of  dealing 
with  the  pedicle,  as,  indeed,  has  everybody  else,  by  reason  of  Dr. 
Keith's  unprecedented  success  with  the  intra-peritoneal  method, 
even  before  he  adopted  antiseptics. 

The  basis  of  the  antiseptic  claim  is  that  the  system  prevents 
septic  poisoning,  that  is*  septic  or  surgical  fever.  Every  one 
who  has  watched  a  number  of  ovariotomies  knows  that  by  far 
the  larger  number  of  deaths  occur  from  the  incidence  of  fever, 
and  that  the  pulse  and  temperature  rise  progressively,  though 
perhaps  with  intermissions,  till  they  reach  the  fatal  vanishing 
points.  With  few  exceptions  this  is  true  of  all  the  deaths  I  have 
had.  If,  therefore,  the  antiseptic  system  favors  a  larger  num- 
ber of  recoveries  by  preventing  the  so-called  septic  fever,  it  is 
an  absolute  certainty  that  the  recoveries  will  be  uniformly  and 
correspondingly  facilitated,  inasmuch  as  in  non-antiseptic  cases 
the  germs  will  enter  every  peritoneum  and  will  theoretically  pro- 
duce fever  in  every  case,  and  only  in  those  cases  where  there  is 


278  DISEASES   OF   THE   OVARIES. 

a  sufficiency  of  an  unknown  something  which  counteracts  the 
septic  poison  will  recovery  be  obtained. 

Equally  according  to  the  theory  will  the  germs  destroyed  by 
the  antiseptic  precautions  enter  the  peritoneal  cavity  harmlessly^ 
being  dead  and  unfit  to  produce  septic  fever. 

Another  step  in  the  syllogism  is  that  as  the  temperature  and 
pulse  curve  are  uniformly  admitted  to  represent  the  course  of 
any  case  involving  febrile  action,  if  the  antiseptic  system  makes 
its  claims  justly,  ovariotomies  performed  under  its  precautions 
ought  to  indicate  a  more  even  and  less  febrile  course  of  re- 
covery than  the  non-antiseptic  cases,  and  this  should  occur  in- 
dependently of  all  other  details  of  the  operation. 

I  would  put  the  possible  conclusion  briefly  thus  :  If  we  find 
a  marked  difference  between  the  curves  of  cases  treated  anti- 
septically  and  those  not  so  in  favor  of  the  former,  then  I  think 
I  may  say  that  more  has  been  done  to  establish  Mr.  Listers 
view  than  anything  I  have  yet  seen.  If  there  be  no  difference, 
then  the  question  is  just  where  it  was  ;  but  if  there  be  a  differ- 
ence on  the  other  side,  then  I  think  the  application  of  the  germ 
theory  to  surgical  practice  will  be  certain  to  fade  away  from 
professional  and  popular  acceptance  just  as  many  fair-looking 
visions  have  done  before. 

In  order  to  test  this  point  as  far  as  I  could  I  took  the  morn- 
ing and  evening  observations  of  the  temperature  and  pulse  for 
each  case  during  a  period  of  ten  days,  and  constructed  for  the 
morning  and  evening  of  each  day  an  average  of  the  total  obser- 
vations under  discussion,  and  marked  this  upon  graphic  paper. 
I  took  ten  days  as  the  limit,  because  I  believed  that  this  ex- 
ceeded by  at  least  three  days  the  average  period  of  stable  re- 
covery in  cases  of  ovariotomy,  and  because  it  was  the  limit  to 
which  the  observations  could  be  extended  with  full  material. 
My  general  impression  was  that  a  successful  ovariotomy  was 
practically  well  on  the  sixth  day ;  but  it  will  be  seen  from  the 
figures  that,  like  other  general  impressions,  this  is  quite  a  mis- 
take, for  convalescence  is  not  fully  established  till  the  eighth 
day,  and  is  certainly  not  complete  on  the  tenth.  Therefore, 
probably  my  conclusions  would  have  been  better  with  more  ex- 
tended observations.  I  also  see  now  that  my  statements  would 
have  been  more  perfect  if  I  had  carried  out  my  fig  ires  to  two 
or  even  three  places,  but  this  would  have  involved  a  great 
amount  of  labor. 

Concerning  the  mere  duration  of  recovery,  some  interesting 
conclusions  were  indicated.  From  the  curves  which  I  con- 
structed from  the  whole  of  the  one  hundred  cases,  it  is  quite 
evident  from  the  pulse  curve,  still  more  from  the  temperature 


OVARIOTOMY.  279 

curve,  that  recovery  takes  a  sudden  progress  forward  on  the 
eighth  day,  but  that  it  is  not  then  complete.  On  the  sixth  and 
seventh  days  the  temperature  gives  distinct  indications  of  exal- 
tation, especially  nocturnal,  and  this  is  clearly  seen,  on  exami- 
nation of  the  constituent  curves,  to  be  due  to  the  suppuration 
consequent  on  the  separation  of  the  clamp,  and  probably,  also, 
on  the  formation  of  stitch-hole  abscesses. 

The  consideration  of  this  curve  leads  me  to  say  that  I  attach 
less  value  to  the  temperature  curves  than  to  the  pulse  curves, 
for  the  reason  that  the  temperature  during  the  course  of  recov- 
ery from  ovariotomy  is  liable  to  extraordinary  explosions.  I 
have  repeatedly  seen  a  patient's  temperature  rise  three  or  four 
degrees,  and  in  one  recent  case  six  degrees  centigrade,  without 
the  slightest  apparent  reason,  the  exaltation  lasting  from  half 
an  hour  to  three  or  four  hours,  and  then  the  temperature  would 
fall  quite  as  rapidly,  leaving  the  patient  without  any  appear- 
ance of  effect,  or  any  record  of  it,  save  on  the  chart.  This  is  not 
the  case  with  the  pulse  curve,  for  if  that  rises  the  general  ap- 
pearance of  the  patient,  and  other  signs  and  symptoms,  amply 
prove  that  something  is  wrong,  and  the  changes  of  the  curve  do 
not  occur  or  give  way  with  rapidity,  but  always  gradually. 
Therefore,  temperature  readings  require  to  be  far  more  numer- 
ous than  pulse  readings  to  give  the  same  uniformity  of  result. 
Pulse  readings  are  also  not  subject  to  such  influence  by  limited 
suppuration  as  temperature  readings,  and  this  is  shown  by  the 
marked  difference  in  the  temperature  and  pulse  curves  on  the 
sixth  and  seventh  days.  Further,  the  temperature  rises  almost 
uniformly  at  night  during  the  progress  of  recovery,  "while  the 
pulse  does  not  do  s  >  after  the  fourth  night,  and  this  confirms 
my  general  impression  that  the  fourth  night  is  the  critical 
night  of  the  course  of  an  ovariotomy.  My  conclusion  is  finally 
confirmed  by  the  fact  that,  while  I  have  seen  a  case  end  badly 
without  the  temperature  rising  to  any  remarkable  height,  I 
have  invariably  found  the  pulse  rise  continuously  till  it  disap- 
peared. 

It  is  made  almost  certain  by  all  that  I  have  seen,  as  far  as 
my  practice  is  concerned  at  least,  that  the  improvement  is  due 
chiefly  to  the  introduction  of  the  intra-peritoneal  treatment  of 
the  pedicle,  and  as  far  as  I  can  discover  there  is  nothing  to  be 
credited  to  antiseptic  precautions,  for  the  difference  in  result 
between  the  ligature  used  under  antiseptic  precautions  and  with- 
out them  is  not  worth  discussing,  and  depends  really  upon  one 
death  in  one  hundred  and  thirty-nine  cases,  and  that  death  was 
not  due  in  any  either  to  septics  or  antiseptics,  but  would  have 
occurred  in  any  case.     I  have  seen  a  case  killed  by  thymol,  and 


280  DISEASES   OF   THE  OVARIES. 

this  agent  has  been,  by  common  consent,  quite  abandoned.  Per- 
haps I  have  never  seen  carbolic  acid  kill  a  patient,  as  it  is  used 
now,  but  I  have  seen  it  produce  very  serious  symptoms,  and, 
therefore,  I  have  entirely  discontinued  Mr.  Lister's  practice  in 
abdominal  surgery  save  in  such  cases  as  those  conjointly  respon- 
sible with  myself  desire  that  it  should  be  employed.  The  only 
detail  I  have  retained  is  the  practice  of  having  my  instruments 
in  a  water-bath,  which  I  find  to  be  an  easy  and  effective  method 
of  keeping  them  clean. 

Dr.  Keith  has  quite  recently  come  to  somewhat  similar  con- 
clusions, and  he  has  given  up  Listerism  for  abdominal  surgery, 
and  he  told  us  at  the  recent  International  Congress,  in  London, 
that  Listerism  would  add  two  or  three  per  cent,  to  the  mortality 
of  ovariotomy.     I  am  certain  he  is  right. 

For  ovariotomy  I  generally  have  the  patient  ansesthetized  on 
the  bed  and  then  lifted  upon  the  table,  the  object  of  this  being 
that  she  is  saved  the  distress  of  seeing  the  preparations  which 
have  been  made  for  the  operation,  as  the  instruments  and  other 
appliances  are  not  brought  into  the  room  until  she  is  uncon- 
scious. When  upon  the  table,  the  arms  and  legs  are  secured  by 
belts,  and  two  clean  towels  are  arranged  so  as  to  leave  the  abdo- 
men exposed  between  them.  I  prefer  this  method  to  the  rubber 
cloth  with  a  hole  cut  in  it,  originally  used  by  the  late  Sir  William 
Ferguson,  for  it  entails  difficulty  in  securing  the  latter  to  the 
patient's  skin,  and,  as  a  rule,  I  have  not  found  that  it  saves  very 
much  mess.  The  bladder  has  previously  been  emptied  by  the 
nurse,  and  I  have  personally  inspected  all  the  arrangements  of 
instruments,  sponges,  etc. ,  to  see  that  nothing  has  been  omitted. 

I  begin  the  incision  midway  between  the  umbilicus  and  the 
pubes  and  cut  downward,  going  completely  through  the  skin 
and  subcutaneous  fat  at  one  cut,  for  a  distance  of  about  two  and 
a  half  inches.  I  then  look  for  the  white  line  and  divide  it  to  an 
equal  extent,  and  after  that  I  cautiously  divide  the  fat  and  trans- 
versalis  fascia  until  the  peritoneum  is  exposed.  A  pause  is  then 
made,  and  every  bleeding  point  is  secured  by  a  pair  of  scissor- 
forceps.  I  never,  in  the  first  instance,  make  an  incision  any 
longer  than  two  and  a  half  inches,  because  I  am  very  averse  to 
making  the  wound  any  larger  than  it  need  be,  and,  as  a  rule, 
three  inches  is  enough.  As  soon  as  all  the  bleeding  points  have 
been  secured,  I  open  the  peritoneum  so  as  to  admit  my  forefin- 
ger, and  with  that  I  make  a  brief  preliminary  exploration.  The 
peritoneum  is  then  laid  open  to  an  extent  corresponding  with 
the  wound  in  the  other  tissues  and  the  cyst  is  exposed,  any  fur- 
ther l>leeding  being  immediately  arrested.  In  this  stage  of  the 
operation,  indeed  throughout  the  entire  proceeding,  I  never  use 


OVARIOTOMY.  281 

any  other  director  than  my  finger,  for  upon  that  I  can  place 
most  reliance.  If  there  should  be  no  adhesions  between  the 
tumor  and  the  peritoneum  in  front,  this  part  of  the  operation 
is  very  simple;  but  if  there  be  adhesions  it  is  often  no  easy  mat- 
ter to  determine  the  point  of  union  between  the  two  membranes, 
and  it  is  in  such  a  state  of  matters  that  inexperienced  operators 
are  apt  to  commit  a  grievous  error.  I  have  twice  known  in- 
stances, and  I  have  heard  of  several  others,  where  the  glistening 
peritoneum  has  been  mistaken  for  the  wall  of  the  cyst,  and  the 
operators  have  industriously  set  to  work  to  separate  the  former 
membrane  from  the  transversalis  fascia.  Sometimes,  even  when 
there  is  no  adhesion,  the  peritoneum  is  so  greatly  altered  in  ap- 
pearance, having  become  so  thick,  leathery,  and  gelatinous,  as 
to  deceive  any  but  the  most  experienced  operator.  When  the 
point  of  union  between  the  cyst  and  peritoneum  cannot  be  dis- 
covered, the  best  way  is  to  cut  cautiously  inward  until  the  cyst 
be  opened,  because  then  it  can  be  emptied,  the  whole  wall  care- 
fully taken  up  and  examined,  and  the  several  parts  accurately 
determined.  This,  however,  wants  great  caution,  for  it  may  be 
that  a  piece  of  intestine  lies  in  the  way  and  may  be  opened  by 
mistake ;  but  the  experiences  of  a  few  cases  will  enable  an  ob- 
servant surgeon  easily  to  determine  when  he  is  cutting  through 
muscular  fibre.  When  the  cyst  is  reached,  it  should  be  tapped 
by  a  large-sized  syphon  trocar  (Fig,  31,  p.  261)  and  emptied  as 
quickly  as  possible.  Sometimes,  however,  the  contents  of  an 
ovarian  cystoma  are  glairy  or  even  perfectly  gelatinous  and  will 
not  pass  through  a  trocar,  and  nothing  tries  the  presence  of  mind 
of  an  inexperienced  operator  more  than  this.  The  peculiar  ad- 
hesive mass  which  sometimes  fills  an  ovarian  cyst  will  neither 
pass  through  a  trocar,  nor  be  seized  by  the  hand  nor  lifted  up  by 
a  sponge,  and  to  remove  it  from  the  cyst  is  often  a  matter  of  the 
greatest  difficulty.  It  was  upon  such  a  tumor  as  this  that  Hous- 
ton performed  the  first  ovariotomy.  In  such  a  case  the  walls  of 
the  cyst  are  generally  thin  and  extremely  fragile,  so  that  they 
cannot  be  held  by  forceps.  Such  tumors  are  also  often  very  ad- 
herent, the  adhesions  bleeding  very  freely  when  broken  down, 
and  many  of  these  cases  are  lost  on  account  of  the  mere  exten- 
sion of  time  required  for  the  removal  of  the  cyst  contents.'  In 
a  case  like  this  there  is  nothing  for  it  but  to  enlarge  the  incision 
to  the  extent  of  four  or  five  inches,  or  even  more,  and  to  remove 
the  mass  by  the  hands  as  rapidly  as  possible,  the  assistant  aid- 

'  In  a  pretty  table  (III.)  in  his  book  Resultats  Statistiques  de  rOvariotomie,  M.  Koe- 
berle  shows  conclusively  how  fatal  protracted  operations  are.  It  follows,  therefore, 
that  in  cases  of  difficulty — and  these  are  the  onlj'  fatal  ones — an  experienced,  skilful, 
and  rapid  operator  is  sure  to  have  by  far  the  best  results. 


282  DISEASES   OF   THE   OVARIES. 

ing  in  the  process  by  squeezing  upon  the  flanks.  If,  however, 
the  cyst  contents  are  fluid  and  the  tumor  consists  mainly  of  one 
cyst  without  adhesions,  nothing  would  seem  more  simple  than 
an  ovariotomy,  and  the  removal  of  a  parovarian  cyst  is  usually 
a  proceeding  which  takes  a  shorter  time  to  perform  than  to  de- 
scribe. 

When  the  cyst  has  been  emptied,  it  should  be  drawn  gently 
out  through  the  wound ;  and  if  non-adherent,  no  obstacle  will 
be  met  with  unless  it  be  the  presence  of  some  secondary  cysts. 
The  trocar  having  been  maintained  in  its  position  by  means  of 
the  spring  catches  at  its  sides,  its  point  should  be  made  to  enter 
these  cysts,  and  thus  empty  them  ;  but  very  often  the  contents 
of  these  secondary  cysts  are  much  thicker  than  the  fluid  con- 
tained in  the  major  ones,  and  sometimes  they  are  so  numerous 
and  of  such  small  size  that  they  constitute  a  solid  mass  at  the 
base  of  the  tumor.  In  such  a  case  I  lay  open  the  major  cyst, 
and,  passing  my  hand  within  it,  I  break  up  into  its  cavity  as 
much  as  I  can  of  the  secondary  cyst  mass,  in  order  to  save  any 
further  enlargement  of  the  abdominal  wound.  During  the 
whole  of  these  proceedings  as  much  care  as  possible  should  be 
taken  to  prevent  any  escape  of  the  cyst  contents  into  the  ab- 
dominal cavity. 

Adhesions  are  mediate  or  immediate,  the  former  being  gen- 
erally parietal  or  omental,  existing  in  the  shape  of  round  or  flat- 
tened bands  of  peritoneum.  They  seem  to  be  formed  by  isolated 
patches  of  adhesion,  which  have  dragged  off  the  peritoneum  from 
the  abdominal  wall,  or  by  pieces  of  adherent  omentum.  They 
are  seldom  large,  and  are  only  of  any  moment  when  traversed 
by  an  important  blood-vessel,  which  must  always  be  secured  by 
torsion  or  ligature,  or  by  the  cautery.  The  immediate  adhe- 
sions require  great  patience  to  overcome  them ;  but  even  when 
they  unite  the  tumors  to  the  most  important  organs,  they  may  be 
separated,  or  a  piece  of  the  cyst  may  be  detached  and  left.  One 
of  the  dangers  of  the  removal  of  an  ovarian  tumor  with  exten- 
sive pelvic  adhesions — and  still  more  of  a  uterine  tumor — is 
damage  to  one  or  both  ureters.  It  will  be  remembered  that 
they  run  down  obliquely  from  the  kidney  over  the  brim  of  the 
pelvis  down  to  the  bladder,  lying  over  on  each  side  of  the  cer- 
vix, and  close  to  it.  I  have  often  laid  them  bare,  but  have  never 
been  unfortunate  enough  to  injure  them.  In  the  celebrated  case 
published  by  Simon  {Chirurgie  der  Nieren.,  1S70),  the  ureter 
had  been  dragged  into  the  wound  and  clamped,  and  the  pa- 
tient recovered,  with  a  urinary  fistula  of  the  left  ureter.  Simon 
heroically  removed  the  left  kidney  and  cured  his  patient,  and 
I  saw  her  alive  some  years  after  the  operation,  and  at  the 


ovAiiioTOMr.  283 

same  time  I  saw  her  tumor  in  one  bottle  and  her  left  kidney  in 
another. 

Nussbaum  had  a  similar  accident,  and  he  cured  his  patient 
by  making  an  artificial  continuation  of  the  ureter  between  its 
divided  points.  When  dividing  the  pedicle  of  a  large  tumor  of 
old  standing,  I  have  several  times  seen  hugely  dilated  lymphatic 
trunks,  which  looked  very  much  like  ureters — a  resemblance 
which  more  than  once  made  me  very  uncomfortable  for  a  few 
days. 

Many  curious  and  exceptional  forms  of  adhesion  occur,  one 
of  the  most  remarkable  of  which  is  occasional  adhesion  of  the  tip 
of  the  vermiform  appendix  of  the  caecum  to  the  tumor.  I  have 
seen  this  three  times,  twice  in  my  own  practice.  The  first  time 
I  saw  it  it  was  unfortunately  divided  by  the  scissors  of  the  oper- 
ating surgeon,  with  a  fatal  result ;  and  it  was  only  the  discovery 
of  this  misfortune  at  the  post-mortem  which  enabled  me  to  re- 
cognize a  similar  condition,  and  avoid  a  like  disaster  in  my  own 
cases.  In  dealing  with  pelvic  adhesions  it  must  be  borne  in 
mind  that  the  large  venous  trunks  in  that  region  lie  immediately 
under  the  peritoneum,  and  that  they  must  be  carefully  avoided. 
In  the  first  operation  I  ever  saw,  one  of  these  trunks  was  torn 
across  by  the  rough  handling  of  an  inexperienced  operator,  and 
I  need  hardly  say  that  death  ensued  in  a  very  few  hours,  be- 
cause it  was  quite  impossible  to  secure  the  bleeding  point,  or 
even  to  find  it.  Immediate  death  was  only  staved  off  by  stuf- 
fing the  pelvis  with  a  towel.  This  event  made  such  a  strong 
impression  upon  me  that  I  thought  it  hardly  possible  I  ever 
could  take  part  myself  in  an  operation  fraught  with  such  terri- 
ble risks.  Hemorrhage  from  adhesions  has  always  a  very 
strong  tendency  to  arrest  itself,  and  most  of  the  bleeding  points 
will  stop  of  their  own  accord,  or  can  be  stopped  by  simple  pres- 
sure with  a  sponge ;  each  point  of  importance  should  be  seized 
by  a  pair  of  scissor-f creeps,  or  touched  with  a  cautery,  or  with 
a  piece  of  solid  perchloride  of  iron.  For  the  arrest  of  a  general 
oozing  from  a  large  surface,  the  pressure  of  two  or  three  dried 
sponges  is  generally  enough,  and  it  is,  therefore,  my  practice 
always  to  separate  adhesions  as  rapidly  as  possible,  and  to  fol- 
low their  separation  by  the  immediate  application  of. sponges, 
leaving  these  in  situ  until  I  have  finished  the  separation  and  re- 
moval of  the  tumor. ' 

'  A  few  days  ago  I  removed  a  tumor  universally  adherent,  full  of  pus,  and  quite 
rotten.  I  tore  across  the  pedicle  before  I  had  recognized  it,  and  its  vessels  bled  jiro- 
fusely.  Like  the  rest  of  the  tissue,  it  was  quite  rotten,  and  the  more  I  tied  the  ves- 
sels the  more  they  bled.  The  cautery  was  equally  useless.  I  therefore  secured  all 
the  points  by  means  of  forceps,  and  left  them  in  situ  in  the  abdomen,  closing  the 


284  DISEASES   OF   THE   OVAKIES. 

Suppose  the  tumor  separated  and  withdrawn,  the  assistant, 
stationed  opposite  the  operator,  should  immediately  insert  one 
or  two  sponges  to  prevent  the  exit  of  the  intestines,  and  he 
should  then  take  possession  of  the  tumor  and  steady  it  while 
the  surgeon  examines  the  pedicle,  and  determines  how  it  may 
best  be  dealt  with. 

At  present,  we  may  say,  there  are  only  three  methods  in 
vogue  for  the  treatment  of  the  pedicle,  and  of  these  one — that  is, 
the  clamp— should  be  reserved  for  extremely  exceptional  in- 
stances. Probably  not  more  than  two  or  three  cases  in  a  hun- 
dred require  now  to  be  dealt  with  by  the  clamp ;  certainly,  I 
have  not  met  with  more  than  one  for  the  last  three  years.  The 
kind  of  pedicle  requiring  the  clamp  is  thick  and  soft,  and  so 
short  as  to  contain,  perhaps,  a  small  piece  of  the  tumor.  With 
such  a  pedicle  the  extra-peritoneal  method  is  admissible,  and 
probably  is  superior  to  treatment  either  by  the  cautery  or  the 
ligature  ;  but  I  am  not  quite  sure  that  a  combination  of  a  drain- 
age-tube with  either  of  these  latter  methods  may  not  yet  be 
found  superior  to  the  clamp.  If  to  the  pedicle  of  an  ovarian 
tumor,  unusually  thick  and  short,  or  in  that  of  a  uterine  tumor, 
it  is  thought  desirable  to  employ  a  clamp,  then  it  is  evident  that 
what  is  wanted  is  a  form  of  circular  constriction  by  some  means 
which  will  completely  arrest  the  hemorrhage,  will  not  cut  the 
pedicle,  and  which  will  allow  the  wound  to  be  accurately  ad- 
justed round  the  stump. 

To  meet  all  these  requirements,  I  have  devised  a  clamp 
(figured  on  opposite  page)  which  has  served  my  purpose  better 
than  any  I  have  seen. 

After  a  large  number  of  experiments  I  selected  thick  copper 
wire  (No.  32,  Birmingham  gauge),  nickeled,  and  completely  soft- 
ened by  being  made  red  hot  and  allowed  slowly  to  cool,  as  being 
the  best  material  to  work  with. 

For  use  I  bend  it  into  a  loop,  as  seen  in  the  right-hand  figure, 
ready  for  the  operation.  After  it  has  been  placed  round  the 
pedicle,  the  collar  B  is  run  on  close  up  to  the  pedicle.  The  han- 
dle A  E  is  then  also  run  on,  the  ends  of  the  wires  running  in 
the  holes  F  F,  and  the  end  A  fitting  into  a  counter-sunk  hole, 
shown  by  a  dotted  line  at  B.  The  pinch-screws  D  D  are  then 
closed  tightly  down  on  the  wires,  the  screws  C  C  being  quite 
loose.  The  handle  at  E  is  then  turned  slowly  till  the  loop  of 
wire  firmly  constricts  the  pedicle.  The  tumor  is  then  removed, 
and  if  there  be  any  bleeding,  a  few  more  turns  of  the  handle  E 

wound  over  them.  I  reopened  it  in  twenty-four  hours,  removed  the  forceps,  refast- 
ened  the  wound  with  a  drainage-tube  at  its  lower  angle,  and  the  patient  made  an  un- 
interrupted recovery. 


OVARIOTOMY. 


285 


will  secure  it.  When  this  is  done,  the  pinch-screws  C  C  are  to 
be  securely  tightened  down  on  the  wire,  and  those  at  D  D  loos- 
ened. The  handle  will  then  come  off,  leaving  the  wire  clamp 
with  its  collar,  as  seen  in  the  right-hand  figure.  The  ends  of 
the  wire  are  then  to  be  turned  slightly  up,  and  the  wound  closed 
and  dressed  as  usual. 

I  have  used  this  clamp  in  thick  pedicles  in  eleven  cases  with 
perfect  success,  and  six  of  those  were  uterine  myomata. 

Of  the  two  intra-peritoneal  methods  of  dealing  with  the  pedi- 
cle, which,  by  common  consent,  have  been  adopted  as  superior  to 
all  others,  it  is  as  yet  extremely  difficult  to  give  preference  to 
one  over  the  other.  In  the  hands  of  Dr.  Keith,  the  cautery,  as. 
originally  introduced  by  Mr.  Baker  Brown,  has  been  brilliantly" 


Fig.  33.— Tait's  Wire  Clamp. 

successful ;  but  in  my  own  hands  the  silk  ligature  has  proved 
not  one  bit  inferior  ;  and  I  shall  retain  it  as  long  as  it  serves  mo 
as  it  has  done  up  to  the  present  moment ;  for  it  could  only  be  by 
careful  comparison  of  the  results  of  a  very  extended  experience 
that  any  determination  would  be  arrived  at  as  to  the  superiority 
of  the  one  over  the  other.  As  soon  as  Dr.  Keith  has  removed 
the  tumor,  he  fastens  on  the  pedicle  the  well-known  cautery 
clamp  of  Mr.  Baker  Brown,  screwing  it  up  very  tightly  ;  he 
then  divides  the  pedicle  above  the  clamp  by  a  common  cautery 
iron  at  a  dull  red  or  almost  black  heat,  searing  the  pedicle  very 
slowly,  but  very  completely.  When  he  removes  the  clamp,  that 
part  of  the  pedicle  which  has  been  embraced  by  it  is  shrivelled 
and  translucent,  like  parchment,  and  it  very  rarely  gives  him  any 


286  DISEASES   OF   THE   OVARIES. 

further  trouble  by  bleeding ;  if  it  should  do  so,  he  screws  it  up 
again  and  applies  the  iron  more  effectually.  He  then  drops  the 
pedicle  back  into  the  cavity  and  proceeds  with  the  further  steps 
of  the  operation.  I  have  watched  him  go  through  the  process 
with  great  interest,  but  I  w^as  not  impressed  by  anything  beyond 
my  previous  convictions,  that  it  is  the  intra-peritoneal  method, 
and  not  any  particular  variety  of  it,  which  gives  the  success  ; 
and  that  the  ligature  as  applied  in  '*  Tait's  knot"  occupies  less 
than  a  tenth  part  of  the  time  taken  by  the  cautery,  and,  I  think, 
must  be  more  secure. 

The  history  of  the  short  ligature  is  given  as  follows  by  Mr. 
Alban  Doran  {St.  Bartholomeivs  Hospital  Reports,  1877)  : 

"  But  Dr.  Nathan  Smith,  of  Connecticut,  the  second  American 
ovariotomist,  in  his  first  operation  in  1831,  not  only  ligatured 
two  arteries  in  the  omentum  with  strips  of  leather  from  a  kid 
glove,  but  also  tied  two  arteries  in  the  pedicle.  This  is  in  ac- 
cordance with  principles  recognized  by  the  most  experienced 
modern  operators,  ligature  of  the  pedicle,  as  a  whole,  being 
hazardous,  since  the  single  thread  is  apt  to  snap.  The  ends  of 
all  the  ligatures  were  cut  short,  and  the  external  wound  closed, 
the  stump  of  the  pedicle  having  been  returned  into  the  abdom- 
inal cavity.  Dr.  Smith,  then,  was  the  first  to  adopt  the  com- 
plete intra-peritoneal  ligature.     The  patient  recovered. 

''In  1829  Dr.  David  Rogers,  of  New  York,  ligatured  separ- 
ately several  large  vessels  in  the  pedicle  of  an  ovarian  cyst,  and 
returned  the  stump  of  the  pedicle,  with  the  ligatures  cut  short. 
The  operation  was  perfectly  successful.  In  1835  Dr.  Billinger 
adopted  the  same  procee  'ing,  with  satisfactory  results. 

"Dr.  Tyler  Smith  appears  to  have  been  the  first  authority 
who  regularly  and  systematically  advocated  complete  intra-peri- 
toneal ligature.  Recently  it  has  been  adopted  in  hundreds  of 
successful  cases  where  the  pedicle  has  been  found  too  short  for 
the  clamp  to  be  safely  applied.  Ligatures  of  bleeding  vessels  in 
omentum  are  also  cut  short.  As  many  as  forty  ligatures  have 
been  left  in  the  abdominal  cavity  without  any  evil  effects." 

My  own  method  of  dealing  with  the  pedicle  is  by  a  piece  of 
silk  thread,  varying  in  thickness  according  to  the  mass  of  the 
pedicle  ;  for  a  thin  pedicle  I  use  thin  silk,  and  for  a  thick  pedicle 
correspondingly  thick  cord,  because,  of  course,  in  the  latter  case 
the  ligature  must  be  pulled  with  much  more  force  than  in  the 
former.  The  method  in  which  I  use  the  ligature  is  that  I  have 
termed  the  Staffordshire  knot,  as  it  is  the  badge  of  the  county  of 
Stafford;  and  the  idea  of  its  use  occurred  to  me  while  travel- 
ling in  a  Staffordsliire  railway  carriage,  in  which  it  was  a  con- 
spicuous ornament.     Mr.  Mazzinghi,  the   learned  custodian  of 


OVARIOTOMY.  287 

the  William  Salt  Library  at  Stafford,  tells  me  that  nothing  is 
known  definitely  as  to  the  origin  of  the  badge,  further  than  that 
it  was  granted  by  the  College  of  Heralds  to  the  county  within 
living  memory,  and  was  copied  from  the  arms  of  the  old  Staf- 
ford family  at  Maxstoke  Castle.     Such  badges  were  used  to  dis- 
tinguish the  adherents  of  noble  families,  and  their  origin  is 
generally  altogether  unknown.     The  legend  in  the  present  case 
is  that  rogues  were  at  one  time  so  numerous  in  Staffordshire 
that  a  knot  had  to  be  devised  which  would  hang  three  at  a  time. 
If  so,  the  original  knot  must  have  differed  from   its   present 
representative,  for  the  latter  could  only  hang  two.     It  is,  how- 
ever, its  remarkable  property  in  this  direc-  ..^5=-^ 
tion  which  has  led  me  to  introduce  its  use     ^^^\  f^^\ 
in  surgery.                                                                f            |  f  | 
The   woodcut  will  show  how  the  knot     \w           i  I     ^^/ 
acts,  and  a  very  brief  description  will  prob-       J^^^^^^^r__ 
ably  make  clear  enough  how  it  is  used.       ^^^"""^"'^ 

,  T  1  111  n  1         ^J^  Fig.  34. —Tait's  "  Staffordshire 

An  ordmary-handled  needle,  armed  with  a  Knot." 

long  piece  of  the  silk  required,  is  passed 

through  the  pedicle  and  then  withdrawn  so  as  to  leave  a  loop  on 
the  distal  side.  This  loop  is  then  drawn  over  the  ovary  or  tumor, 
and  one  of  the  free  ends  drawn  through  it,  so  that  one  end  is 
above,  while  the  other  is  under,  the  retracted  loop.  Both  ends 
being  seized  in  the  hand,  they  are  drawn  through  the  pedicle, 
against  which  the  thumb  and  forefinger  of  the  left  hand  are 
pressed  as  a  fulcrum,  till  complete  constriction  is  made.  A  sim- 
ple hitch  is  then  made,  as  in  the  drawing,  and  tightened  ;  and 
that  is  followed  by  another,  as  in  ordinary  ligature-tying.  There 
is  another  and  more  complicated  way  of  making  the  knot,  by 
passing  each  end  of  the  thread  round  the  corresponding  half  of 
the  pedicle,  and  crossing  them  within  the  loop  in  front,  which  is 
equally  effective,  and  which  may  be  used  in  cases  of  large  solid 
tumors.  But  the  former  way  is  by  far  the  more  elegant  and 
rapid  method. 

The  advantages  of  this  knot  over  all  others  are  that,  while  it 
ties  the  pedicle  in  two  halves,  these  halves  are  compressed 
really  into  one  surface  ;  the  two  halves  are  equally  well  com- 
pressed ;  and,  from  the  mechanical  arrangement  of  the  knot, 
very  great  constricting  force  can  be  employed  ;  and  in  this  re- 
spect it  greatly  excels  Dr.  Peaslee's  chain-ligature.  I  have  used 
it  now  about  two  hundred  times  and  it  has  never  failed  me  on 
one  single  occasion.  I  cut  the  pedicle  through  about  a  quarter 
of  an  inch  on  the  distal  side  of  the  ligature  and  drop  it  back. 
It  may  very  reasonably  be  asked  what  becomes  of  a  ligature  so 
disposed   of,  and,  fortunately  for  me,  I  am  wholly  unable  to 


288  DISEASES   OF  THE   OVARIES. 

answer  the  question,  for  I  have  not  yet  had  an  opportunity  of 
seeing  one  on  which  I  have  placed  it.  I  therefore  gladly  accept 
the  description  given  by  Mr,  Alban  Doran,  in  the  St.  Bartholo- 
mew's Hospital  Reports  for  1877  : 

"In  1872  Dr.  Bantock  exhibited  before  the  Obstetrical  Society 
the  stump  of  an  ovarian  pedicle  from  a  patient  who  died  of 
cancer  one  year  after  double  ovariotomy  had  been  performed 
upon  her.  The  hempen  ligature  applied,  with  its  ends  cut  short, 
to  one  of  the  pedicles,  was  found  on  dissection  to  have  been 
completely  absorbed,  excepting  its  knot,  which  remained  as  a 
hard  body  the  size  of  a  hemp-seed,  covered  by  peritoneum. 
The  bulging  of  the  tissues  over  each  side  of  the  groove  formed 
by  the  ligature  had  brought  the  strangulated  portion  of  the 
stump  at  once  into  close  contact  with  the  unstrangulated  proxi- 
mal part.  Through  the  slight  irritation  produced  at  first  by  the 
pressure  of  the  ligature,  the  proximal  part  had  thrown  out 
plastic  lymph,  which  had  conveyed  nutritive  plasma  and  also 
capillaries  to  the  distal  portion  of  the  stump,  and  thus  saved 
it  from  gangrene.  In  a  case  like  this,  the  stump  ultimately 
atrophies,  for  reasons  evident  to  any  surgeon  with  a  superficial 
knowledge  of  pathology.  As  for  the  ligature,  it  is  destroyed  in 
the  manner  demonstrated  by  the  experiments  of  Spiegelberg 
and  Waldeyer." 

Hegar  has  described  a  case  where  the  pedicle  sloughed  and 
was  passed  en  7uasse  by  the  rectum,  and  on  it  was  found  the  liga- 
ture which  had  beei  ■  applied.  The  patient  passed  successfully 
through  this  terrible  ordeal,  and  I  hope  her  accident  will  remain 
without  imitation. 

The  next  step  of  the  operation  is  to  examine  the  other  ovary, 
and  if  this  be  found  diseased,  to  remove  it  in  a  similar  way  ;  and 
I  cannot  help  thinking  that  the  cases  are  much  more  numerous 
than  they  used  to  be  in  which  it  is  becoming  necessary  to  re- 
move the  second  ovary  on  account  of  cystic  growth.  Certainly, 
both  in  my  own  practice  and  in  those  of  others  which  I  have  had 
an  opportunity  of  seeing,  the  second  ovary  has  been  diseased 
and  has  required  removal  more  frequently  than  used  to  be  the 
case. 

An  exceptional  method  of  dealing  with  the  pedicle — the  one 
introduced  by  Dr.  Miner  and  called  enucleation — deserves  no- 
tice, because  it  must  occasionally  be  resorted  to  in  cases  of  sessile 
tumors.  It  is  by  no  means  easy  of  performance  and  always 
gives  rise  to  very  troublesome  hemorrhage.  This  method  con- 
sists in  opening  the  peritoneal  capsule  at  the  base  of  the  tumor, 
and  scratching  or  dissecting  out  the  cyst  from  the  matrix  in 
which  its  base  is  placed.     Each  bleeding  point  must  be  carefully 


OVARIOTOMY.  289 

secured  as  it  is  divided,  and  when  the  tumor  is  removed  the 
peritoneal  stump  must  be  gathered  together  and  tlie  edges  fas- 
tened by  sutures,  just  as  in  an  amputation.  I  have  three  times 
employed  this  method  with  eminently  satisfactory  results  ;  but  I 
am  bound  to  say  that  without  a  good  deal  of  experience  in  the 
separation  of  adhesions  I  would  have  stopped  in  the  middle  of 
the  process  and  left  it  incomplete,  on  account  of  its  difficulties. 

The  next  duty  of  the  surgeon  is  to  carefully  cleanse  the  perito- 
neal cavity  from  all  blood-clots  and  other  dehrns  which  may  be  in 
it.  For  the  introduction  of  this  practice  and  the  extreme  care  with 
which  it  is  now  done,  as  well  as  for  the  excellent  results  obtained 
from  it,  we  are  entirely  indebted  to  Dr.  Keith,  though  we  find 
that  he  was  partly  anticipated  by  McDowell,  who  tells  us,  in  his 
description  of  second  operation:  "Notwithstanding  my  great 
care,  a  quart  or  more  of  blood  escaped  into  the  abdomen;  and, 
after  the  hemorrhage  ceased,  I  removed,  as  cleanly  as  possible, 
the  blood,  in  which  the  bowels  were  completely  enveloped."  So 
highly  important  do  I  consider  careful  attention  to  this  precau- 
tion that  I  make  no  apology  for  giving  the  following  some- 
what lengthy  extract  from  Dr.  Marion  Sims'  description  of  Dr. 
Keith's  method  : 

"  When  Dr.  Keith  performed  his  first  operation  in  1862,  he 
was  surrounded  by  old  men  in  the  profession  who  had  a  dread 
of  wounding  the  peritoneum  continually  before  their  eyes.  He 
was  obliged  to  break  up  extensive  adhesions,  and,  as  a  conse- 
quence, there  was  free  exudation  of  blood.  Before  closing  the 
external  wound  he  began  to  sponge  out  the  peritoneal  cavity 
and  suddenly  thrust  a  large  sponge  down  into  the  pelvis  and 
brought  it  up  saturated  with  blood.  Squeezing  it  dry,  he  was 
about  to  repeat  this  process,  when  they  all  united  in  begging  him 
not  to  do  it,  as  from  their  stand-point  there  would  be  more  danger 
in  irritating  the  delicate  peritoneum  with  the  sponge  than  by 
leaving  the  blood  there  to  be  absorbed.  He  yielded  against  his 
judgment  and  closed  the  wound,  leaving  a  large  quantity  of 
blood  in  the  peritoneal  cavity.  On  the  third  day  afterward  his 
patient  was  profoundly  septicsemic,  and  in  imminent  danger. 
He  recognized  the  source  of  danger  and  had  the  courage  to  open 
the  lower  angle  of  the  wound,  by  removing  two  or  three  sutures. 
There  was  an  immediate  discharge  of  fetid  bloody  serum  in 
large  quantities,  and  from  that  moment  the  patient  began  to  im- 
prove and  soon  got  well.  This  made  a  profound  impression  on 
Dr.  Keith's  mind,  and  he  determined  from  that  time  never  again 
to  leave  extravasated  blood  in  the  peritoneal  cavity  if  he  could 
possibly  remove  it.  It  was  not  long  before  he  had  an  oppor- 
tunity of  putting  this  principle  to  the  test  of  experiment,  for  his 
19 


290  DISEASES    OF   THE   OVARIES. 

second  case  was  a  very  bad  one,  Avith  extensive  adhesion.  He 
had  to  tie  many  vessels  and  bleeding  points.  There  was  a  large 
exudation  of  blood  in  the  pelvic  cavity,  and  he  sponged  it  all  out 
thoroughly,  after  which  he  closed  up  the  external  wound,  and  his 
patient  recovered  without  a  single  bad  symptom.  From  this  time 
he  adopted  the  principle  of  never  closing  an  external  wound  till 
he  had  controlled  all  oozing  of  blood  and  made  sure  that  the  peri- 
toneal cavity  was  dry  and  clean."  I  have  seen  Dr.  Keith  do  this, 
and  there  can  be  no  doubt  that  in  this,  as  in  other  respects,  he 
has  greatly  added  to  the  success  of  ovariotomy. 

This  process  has  been  called  by  the  German  surgeons  the 
''toilet  "  of  the  peritoneum,  and  no  care  can  be  too  great  in  its 
performance.  I  generally  clean  out  the  cavity  of  the  pelvis  and 
the  hollow  of  each  loin  by  two  or  three  sponges,  and  then  fill  the 
whole  abdomen  full  of  tepid  water  by  means  of  a  tube  running 
from  a  ewer  or  a  suspended  cistern,  closing  the  wound  as  well  as 
I  can  with  one  hand  while  the  other  is  inside.  I  move  my  fingers 
rapidly  about  among  the  intestines  and  give  them  a  good  wash 
in  the  water.  I  then  empty  the  cavity  and  refill  it  two  or  three 
times  until  the  water  comes  out  quite  clear.  In  this  way  I  very 
rapidly  determine  if  there  is  any  bleeding,  because  even  a  small 
point  will  perceptibly  tinge  the  water  I  have  poured  in  ;  and  if 
the  water  continues  colored  I  immediately  hunt  about  until  I 
have  found  and  s  Jcured  the  bleeding  point.  After  the  cleansing 
has  been  satisfactorily  accomplished  I  put  a  number  of  dry 
sponges  down  in  the  pelvis  and  over  each  kidney  and  then  pro- 
ceed to  insert  the  sutures  in  the  wound.  By  the  time  this  is  ac- 
complished the  dry  sponges  have  soaked  up  all  the  water,  and  the 
peritoneum  is  generally  found  quite  clean  and  dry.  But  if  it 
should  not  be  satisfactorily  so,  I  repeat  the  process  until  I  am 
quite  certain  nothing  has  been  left  behind,  and  in  this  way  I  be- 
lieve I  have  added  largely  to  the  success  of  my  practice. 

Dr.  Keith  places  great  reliance  on  the  use  of  drainage-tubes  as 
originally  introduced  by  Koeberle  in  18G7,  and  improved  by  him- 
self ;  and  this  is  a  practice  I  have  employed  frequently  of  late  and 
I  think  with  very  great  advantage.  Dr.  Keith  used  to  think  the 
Listerian  method  obviated  the  necessity  for  drainage,  and  that  by 
its  employment  any  fluid  left  in  the  abdomen  was  prevented  from 
decomposing  ;  but  my  own  experience  satisfies  me  that  neither 
of  them  need  be  used  if  the  abdomen  can  be  properly  cleansed 
and  dried.  Dr.  Keith  has  now  given  up  Listerism  and  his  re- 
sults are  quite  as  good  without  it  as  with  it,  perhaps  better,  for 
he  has  had  two  deaths  from  carbolic  acid  poisoning.  I  think  the 
peritoneum  itself  will  do  a  great  deal  of  work  in  removing  the 
debris  ;  but  the  surgeon's  object  should  be  to  give  it  as  little  un- 


OVARIOTOMY.  291 

necessary  employment  as  possible,  and  therefore  I  adhere  most 
closely  to  Dr.  Keith's  practice  in  this  respect,  and  to  it  I  may 
largely  attribute  my  increased  success.  Finally,  I  take  the  ut- 
most care  with  the  sutures  to  see  that  they  are  ranged  evenly, 
that  they  include  all  the  structures  of  the  abdominal  wall,'  that 
the  stitch-holes  do  not  bleed,  and  that  the  wound  is  most  accurate- 
ly closed.  I  am  never  satisfied  to  leave  an  eighth  of  an  inch  of 
gaping  wound,  and  I  take  the  utmost  care  that  the  edges  of  the 
skin  are  in  correct  adaptation.  I  always  use  silk  sutures,  and  in- 
troduce them  generally  by  means  of  a  large  crochet  needle.  In 
fastening  the  sutures,  as  well  as  in  tying  all 
ligatures  which  are  not  transfixed,  I  always 
use  the  knot  here  figured,  having  two  turns 
in  its  first  hitch,  so  that  when  this  is  pulled 
tight  it  does  not  slip  before  the  second  hitch 
is  made  and  drawn  up.  For  ligatures  that 
are  transfixed  I  use  the  Staffordshire  knot. 

For  the  first  dressing  of  the  wound  I  use 
nothing  but  the  absorbent  cotton-wool  intro-  fi«- ss.-Doubie-hitch  Knot. 
duced  by  Mr.  Sampson  Gamgee,  and  I  know  of  no  greater  addi- 
tion to  our  means  of  treating  wounds  than  this  simple  material. 
It  is  made  up  into  pads  of  different  sizes  and  shapes,  averaging 
about  five  inches  square,  and  from  one  and  a  half  to  two  inches 
thick.  Two  or  three  of  these  are  placed  over  the  wound  and 
are  secured  in  their  places  by  two  or  three  narrow  straps  of 
sticking-plaster,  the  whole  dressing  being  covered  by  a  cotton 
binder  round  the  patient's  waist,  and  this  is  fastened  with  safety- 
pins.  This  dressing  is  rarely  touched  before  the  fourth  day, 
when  fresh  padding  is  adjusted.  On  the  sixth  or  seventh  day 
I  remove  every  alternate  stitch  and  the  rest  are  removed  on  the 
day  following,  and  it  is  quite  an  unusual  thing  to  find  the  wound 
otherwise  than  completely  and  permanently  united. 

In  the  Medical  Times  of  March,  1874,  Dr.  S.  G.  Stephens,  of 
Rio  Bueno,  Valdivia,  Chili,  gives  an  account  of  an  "  Ovariotomy 
under  DiflSculties,"  which  is  such  a  splendid  instance  of  surgical 
pluck,  crowned,  fortunately,  with  success,  that  I  wish  to  do  what 

'  A  great  deal  of  fuss  has  recently  been  made  concerning  some  experiments  per- 
formed by  Mr.  Spencer  Wells  on  rabbits  and  other  animals,  relative  to  the  inclusion  of 
the  peritoneum  in  the  stitches,  and  it  is  claimed  by  Mr.  Wells  that  by  these  experiments 
hundreds  of  women's  lives  have  been  saved.  As  it  is  a  surgical  rule  to  secure  the 
CO  aptation  of  all  divided  structures,  as  it  never  was  doubted  that  the  peritoneum  was 
an  exception  to  this  rule,  Mr.  Spencer  Wells'  experiments  were  altogether  needless, 
and  contributed  nothing  whatever  to  the  advance  of  abdominal  surgery'.  In  many 
instances  I  have  been  obliged  to  leave  the  peritoneum  out  of  the  stitches,  and  I  never 
saw  that  this  exclusion  made  the  least  difference  to  the  patient's  recovery. 


292  .    DISEASES    OF   THE   OVARIES. 

little  I  can  to  commemorate  the  hero,  and  therefore  I  give  his 
account  here  in  full  : 

"We  had  to  send  to  Valdivia  for  chloroform — four  days' 
journey.  In  the  meantime  I  occupied  myself  in  preparing  the 
patient,  in  considering  with  what  instruments  I  was  to  perform 
the  operation,  and  selecting  and  instructing  my  assistants.  The 
instruments  were  a  trocar  made  from  a  piece  of  colhuihue ' 
about  ten  inches  long,  hollowed  out,  and  sharpened  to  a  point  at 
one  end,  and  at  the  other  connected  with  a  piece  of  india-rubber 
tubing  from  an  enema  syringe;  the  instruments  from  a  '  Char- 
riere '  pocket-case,  and  a  pair  of  craniotomy  forceps.  The  as- 
sistants were  a  Catholic  missionary,  two  Indians,  and  a  half- 
blood.  The  ligature  was  made  of  raw-hide,  with  two  pieces  of 
wood  fastened  at  the  ends,  in  order  that  more  power  could  be 
used  in  pulling  it  tight,  and  at  the  time  of  using  it  was  to  be 
dipped  in  warm  neatsfoot  oil. 

''  The  pedicle  was  rather  long,  but  flat ;  the  raw-hide  ligature 
was  applied  to  it,  and  tightened  by  means  of  the  two  pieces  of 
wood  pulled  by  the  two  assistants  on  each  side  of  the  body  until 
it  was  almost  buried  in  the  parts,  and  then  made  fast  with  two 
lasso-knots,''  the  ends  cut  off,  and  the  whole  dropped  into  the 
cavity.  The  cavity  was  mopped  out  with  cotton-wool,  and  the 
wound  closed  with  fine  iron-wire  sutures,  pushed  through  from 
within  outward  and  twisted,  and  a  superficial  continuous  su- 
ture of  silk.  Water-dressing  was  next  applied,  and  a  warmed 
bayeta  flannel  roller  passed  twice  round  the  body.  Conscious- 
ness returned  before  I  could  get  her  off  the  table,  owing  to  the 
priest  not  attending  to  the  chloroform,  being  too  occupied  and 
astonished  at  my  movements  ;  in  fact,  throughout  the  whole 
proceedings  I  had  constantly  to  attend  to  the  pulse.  Great 
exhaustion  followed ;  and  I  had  first  to  administer  warm  wine- 
and-water,  and  afterward  warm  whiskey-and-water,  apply  fric- 
tion to  the  extremities,  until,  finally,  at  five  o'clock  in  the  after- 
noon, she  had  improved  very  much,  with  a  pulse  at  115,  and 
the  surface  warm  and  moist.  My  thermometer  was  broken, 
so  I  could  not  note  the  temperature.  I  remained  in  the  neigh- 
borhood twelve  days  to  attend  to  her,  during  which  time  she 
went  on  well,  with  the  exception  of  a  little  vomiting  the  day 
after  the  operation,  owing  to  the  husband  giving  her  warm 
lamb's  blood  without  my  knowledge.  The  first  pair  of  sutures 
were  removed  on  January  28th,  and  so  on,  day  by  day,  one  or 

'  A  species  of  bamboo. 

'  One  on  each  side — i.  c.  one  tied  first,  and  then  the  ends  carried  round  to  the 
opposite  side ;  a  slit  made  in  one  end,  and  the  other  cut  in  the  form  of  a  knob,  which 
passes  through  it,  thus  preventing  slack  juing  through  swelling. 


OVARIOTOMY.  293 

more  was  removed,  until  the  niiitli,  or  middle  one,  was  taken 
out. 

"  Never  having  seen  the  operation,  nor  read  any  special  work 
on  the  subject,  I  had  nothing  to  direct  me  but  the  short  account 
given  in  the  last  edition  of  Dr.  Tanner's  '  Practice  of  Medicine.' " 

Occasionally  we  are  called  upon  to  deal  with  an  ovarian 
tumor  in  a  woman  who  is  pregnant — a  complication  which  may 
or  may  not  be  discovered  before  the  operation.  Some  years  ago 
the  question  of  the  propriety  of  removing  an  ovarian  tumor  in  a 
pregnant  woman  was  discussed  before  one  of  the  medical  socie- 
ties, and  various  opinions  were  given.  By  some  obstetric  physi- 
cians the  opinion  was  expressed  that  it  would  be  better  to  induce 
premature  labor,  and  that  after  the  patient  had  recovered  from 
this,  we  should  perform  ovariotomy.  Mr.  Spencer  Wells  and 
myself,  on  the  other  hand,  contended  that  it  would  be  much 
better  to  perform  ovariotomy,  and  leave  the  pregnancy  alone, 
and  this  plan  has  now  become  the  accepted  practice.  At  that 
time  Mr.  Wells  had  operated  upon  ten  pregnant  women,  and  nine 
of  these  cases  were  successful.  I  do  not  know  what  his  experi- 
ence may  have  been  since,  and  I  have  not  found  any  record  of 
the  experience  of  a.ny  one  else  upon  this  subject ;  but  since  the 
discussion  I  have  operated  upon  ten  pregnant  women  with  uni- 
form success.  Before  that  time  I  had  only  operated  in  one  such 
case.  The  result  was  fatal,  and  was  undoubtedly  due  to  the  use 
of  the  clamp,  for  the  cause  of  death  was  gangrene  of  the  pedicle. 
I  do  not  now  think  pregnancy  offers  any  bar  to  the  operation. 
In  all  of  my  cases  I  have  been  able  to  recognize  the  pregnancy 
before  I  opened  the  abdomen  ;  but  I  can. easily  imagine  that  it 
might  occur  to  the  most  experienced  surgeon  to  operate  on  a 
woman  in  whom  he  had  not  previously  recognized  the  existence 
of  the  complication.  Indeed,  Mr.  Wells  tells  us  of  a  case  in 
which  he  punctured  a  pregnant  uterus  with  a  trocar,  having 
mistaken  it  for  a  cyst.  He  opened  the  uterus,  emptied  it  of  its 
contents,  and  the  patient  recovered.'  This  is  one  of  the  compli- 
cations, therefore,  to  be  especially  borne  in  mind.  The  usual 
color  and  appearance  of  an  ovarian  cyst  is  as  a  rule  sufficiently 
characteristic  to  make  it  easily  recognizable  from  a  pregnant 
uterus  ;  yet  I  can  easily  imagine  circumstances  such  as  Mr. 
Wells  encountered,  that  would  lead  to  such  a  mistake  ;  and 
should  this  misfortune  happen,  the  bold  proceeding  he  followed 
would  certainly  be  the  best  practice. 

We  not  unfrequently  find  tumors  of  the  uterus  associated 

^  A  similar  accident  happened  to  Dr.  Byford,  of  Chicagfo.  and  he  successfnlly  fol- 
lowed out  the  same  practice  as  did  Mr.  Wells.  (Americau  Journal  of  Obstetrics, 
January,  1879.) 


294  DISEASES   OF  THE   OVARIES. 

with  cystic  disease  of  the  ovaries.  It  has  happened  to  me  very 
frequently  to  find  a  very  large  part  of  the  mass  which  I  believed 
to  be  entirely  ovarian  formed  of  a  uterine  myoma  associated 
with  an  ovarian  cystoma.  Under  such  circumstances  the  prac- 
tice now  universally  adopted  is  to  remove  the  ovarian  tumor 
and  leave  the  uterine  mass  alone,  but  formerly  it  was  regarded 
as  the  correct  practice  to  remove  both.  Further  on  I  shall  deal 
again  with  this  important  subject,  but  here  I  will  say  it  is  my 
uniform  practice  now,  when  I  find  a  uterine  myoma  in  existence 
as  well  as  an  ovarian  tumor,  to  remove  both  ovaries  and  tubes, 
as  in  this  way  we  can  arrest  the  growth  of  the  tumor  we  cannot 
remove  ;  indeed,  in  some  of  my  cases  the  tumor  has  entirely 
disappeared. 

One  of  the  most  interesting  additions  to  our  advances  in  ab- 
dominal surgery  is  that  originally  derived  from  an  operation 
performed  by  Dr.  Wiltshire,  who  removed  an  ovarian  tumor 
from  a  woman  suffering  from  symptoms  of  the  utmost  gravity, 
due  to  peritonitis  and  gangrene  of  the  tumor.  The  case  is  de- 
scribed in  the  "Transactions  of  the  Pathological  Society"  for 
1868,  the  operation  having  been  performed  in  May  of  that  year. 

Rapid  increase  of  the  tumor  had  taken  place,  and  there  were 
symptoms  of  the  most  urgent  kind  present.  Vomiting  had  been 
incessant  for  three  days,  when,  after  unusual  exertion,  rapid 
enlargement  of  the  tumor  had  begun.  The  pulse  was  quick  and 
feeble,  the  extremities  blue,  and  the  patient's  general  condition 
one  of  collapse, 

The  extreme  tension  of  the  abdominal  parietes  was  shown 
by  the  way  in  which  the  tumor  shot  up  into  the  wound  directly 
the  incision  reached  the  peritoneal  cavity ;  it  had  also  rotated. 
Blood  escaped  on  puncture,  and  at  one  place  the  cyst  wall  gave 
way  when  touched,  owing  to  extreme  thinness.  The  pedicle 
was  rotten,  and  the  right  cornua  of  the  uter-us  had  to  be  trans- 
fixed and  tied  to  arrest  hemorrhage. 

The  tumor  proved  to  be  of  the  right  ovary  and  multilocular, 
the  loculi  being  distended  with  blood.  It  had  rotated  on  its  ped- 
icle four  days  before  the  operation,  strangulation  ensuing.  Tbe 
twist  was  from  right  to  left,  and  appeared  to  have  given  two 
turns.     The  pedicle  was  quite  small  and  short. 

I  think  sufficient  praise  can  hardly  be  given  to  Dr.  Wiltshire 
for  his  courage  in  j)erforming  the  operation  under  such  urgent 
conditions,  and  it  is  not  too  much  to  say  that  to  his  success  in 
this  case  we  owe  a  new  departure  in  the  practice  of  abdominal 
surgery  by  which  operations  under  acute  symptoms  are  under- 
taken, and,  apparently,  with  results  as  satisfactory  as  those 
obtained  in  cases  free  from  emergency. 


OVARIOTOMY.  295 

This  remarkable  axial  rotation  is  an  incident  in  the  life-his- 
tory of  ovarian  tumors,  which  has  not  yet  received  as  much 
attention  as  either  its  importance  or  its  frequency  deserves, 
and,  so  far  as  I  know,  no  perfectly  satisfactory  explanation  of 
the  method  of  its  occurrence  has  been  given. 

So  far  as  I  can  find,  the  first  notice  of  the  incident  is  made 
by  the  same  author  who  has  written  most  about  it,  Hofrath  Pro- 
fessor Carl  Rokitansky,  who  describes  it  in  his  "  Handbuch  der 
Pathologischen  Anatomic"  (vol.  i.)  in  1841.  There  the  descrip- 
tion is  not  full,  but  it  is  certain  that  he  had  then  seen  it,  and  in 
his  future  papers  he  tells  more  about  it  than  does  any  other 
author  ;  indeed,  most  other  writers  have  taken  their  descriptions 
from  him  with  more  or  less  acknowledgment. 

I  have  found  reference  to  a  note  of  a  paper  by  him  in  the 
Allgemeine  Wien  Medizinische  Zeitschrift  for  1840,  but  have  not 
been  able  to  find  the  original  paper.  Possibly  the  note  in  ques- 
tion is  a  misprint,  though  the  title  is  given  in  full,  "Ueber  Ab- 
schnerung  der  Tuben  und  Ovarien  und  ueber  Strangulation  der 
Letzeren  durch  Achsendrehung." 

Rokitansky  has  also  written  very  full  papers  in  the  Allge- 
meine Wiener  Medizinische  Zeitung,  1860;  in  the  ZeitscJu^ift 
der  K.  K.  Gesellschaft  der  Aerzte  in  Wien,  1865;  "Ueber  der 
Strangulation  von  Ovarialtumoren  durch  Achsendrehung." 

Dr.  Van  Buren  narrates  two  cases  in  which  he  noticed  the 
twisting  of  the  pedicle  of  an  ovarian  tumor,  in  the  New  York 
Journal  of  Medicine,  1850  and  1851. 

In  the  first  the  tumor  was  on  the  left  side,  but  the  direction 
of  the  twist  is  not  given.  The  twist  had  not  strangulated  the 
tumor,  and  did  not  hasten  the  ovariotomy,  which  was  success- 
ful. 

The  second  case  was  one  in  which  acute  peritonitis  was  diag- 
nosed on  August  28th,  and  the  patient  died  on  September  8th. 
On  post-mortem  examination  the  tumor  was  found  very  dark  in 
color,  almost  black.  It  was  a  tumor  of  the  right  ovary,  but  the 
direction  of  the  twist  is  not  stated.  "  The  twisting  of  the  pedi- 
cle interrupted  entirely  the  circulation,  the  tumor  thus  became 
engorged  with  blood,  thence  peritonitis,  followed  by  enteritis, 
causing  death."  The  tumor  had  made  one  and  a  half  revolu- 
tions only,  the  pedicle  being  short. 

Dr.  Patruban  (Oesterreiches  Zeitschrift  fiir  practisclie  Heil- 
kunde,  1855)  publishes  a  case  where  the  torsion  produced  rapidly 
fatal  intracystic  hemorrhage. 

Dr.  Crome,  of  Brooklyn  {American  Medical  Monthly,  1861), 
had  a  case  where  the  strangulation  occurred  twenty-four  hours 
before  labor  in  a  small  tumor,  the  patient  dying  of  peritonitis 


296  DISEASES   OF   THE   OVARIES. 

on  the  fifth  day.  The  accident  was  indicated  by  the  access  of 
agonizing  pain  in  the  left  side.  Tlie  cyst  was  found  ruptured 
and  in  a  state  of  gangrene. 

In  his  book  on  "  Diseases  of  the  Ovaries,"  Mr.  Spencer  Wells 
mentions  that,  during  his  first  five  hundred  cases,  he  found  the 
pedicle  twisted  in  about  twelve  cases,  but  no  mention  is  made  of 
any  of  the  tumors  being  consequently  gangrenous,  or  that  the 
operation  was  thereby  hastened. 

In  the  Archiv  flir  Oynecologie  for  1^/8,  Dr.  Veit,  of  Berlin, 
quoting  Schroeder,  says,  tliat  in  his  94  cases  of  ovariotomy, 
axial  rotation  was  observed  13  times,  and  Olshausen  is  of  opin- 
ion that  the  tumors  are  generally  non-adherent. 

Dr.  St.  John  Edwards,  of  Malta,  has  published  a  case  in  the 
Lancet,  of  October,  1861,  in  which  he  had  recognized  an  ovarian 
tumor  during  the  lady's  first  pregnancy.  Her  second  labor  oc- 
curred prematurely,  sudden  abdominal  pain  supervened  on  the 
second  day  after,  and  she  died  on  the  fourth.  The  tumor  was 
found  to  be  of  a  livid  purple  color,  with  patches  of  extravasated 
blood,  and  rents  in  its  walls.  The  right  ovary  was  flattened  out 
on  its  under  aspect  (so  that  it  must  have  been  a  parovarian  cyst). 
The  pedicle  was  two  inches  long,  and  had  been  twisted  one  and 
a  half  times  round.  It  was  intensely  congested,  and  the  ovary 
was  full  of  dark  extravasated  blood  (closely  resembling  one  of 
my  own  cases).  There  was  no  peritonitis,  and  the  tumor  was 
absolutely  free  from  adhesions.  The  contents  of  the  sac  were 
claret-like.  He  attributes  the  twisting  to  the  expulsive  action 
of  the  uterus,  though  the  accession  of  pain  was  not  till  about 
forty-eight  hours  after  labor. 

In  the  Edinburgh  Medical  Journal  I  published  the  following 
case,  which  I  desire  to  reproduce  here,  as  it  was  the  first  of  my 
experience  of  this  remarkable  accident : 

On  August   18,   18G8,   I  was  called  in  consultation  by  my 

friend,   Mr.  Lorraine,  of  Wakefield,  to  see  Mrs.  C ,  aged 

forty-eight,  who  was  suffering  from  a  strangulated  femoral 
hernia.  I  found  the  tumor  of  small  size,  that  the  symptoms 
had  existed  only  two  days,  and  that  it  was  irreducible  by  the 
taxis  under  chloroform.  I  suggested  a  full  dose  of  belladonna 
and  a  delay  of  six  hours.  At  the  end  of  that  period  I  again 
tried  the  taxis  under  chloroform,  but  without  being  able  to  re- 
duce the  hernia,  so  I  at  once  performed  Gay's  operations,  divided 
Gimbernat's  ligament  freely,  and  without  any  trouble  succeeded 
in  returning  the  bowel. 

At  7.30  on  the  morning  of  the  19th  she  was  much  relieved, 
free  from  pain,  and  the  vomiting  had  quite  ceased.     Opium  was 


OVARIOTOMY.  297 

administered  freely,  and  iced  brandy-and-water  or  Moselle  ad 
libituni. 

August  20th,  8  A.M. — The  abdomen  was  slightly  tympanitic, 
and  the  pulse  about  140,  the  patient  being  free  from  pain  and 
sickness.  8  p.m. — Tympanitis  increased  ;  ordered  a  turpentine 
stupe. 

August  21st,  8  A.M. — Tympanitis  so  extreme  that  I  enter- 
tained tlie  idea  of  puncturing  the  intestines.  Temperature  in 
axilla,  101.6°;  no  pain  or  sickness,  and  she  takes  beef-tea  and 
stimulants  freely;  face  very  anxious  in  expression.  10  p.m. — Mr. 
Lorraine  had  seen  her  in  the  afternoon,  and  reported  that  she 
was  somewhat  better.  When  we  met  we  found  that  the  disten- 
tion was  much  less  ;  there  was  no  pain  'and  no  narcotism,  as  the 
opium  had  been  intermitted  ;  rectum  examined  per  vaginam, 
and  found  quite  empty;  temperature  in  axilla,  101°. 

August  22d. — In  the  forenoon  she  had  two  moderately  sized 
and  very  offensive  stools  ;  in  the  afternoon  she  was  seen  by  my 
friend,  Mr.  Kemp  (in  whose  practice  the  case  occurred),  who  no- 
ticed, and  remarked  to  me  afterward,  that  the  breath  had  the 
hay  odor.  At  10  p.m.  I  saw  her  with  Mr.  Lorraine,  and  we  both 
noticed  the  musty  smell  of  the  breath.  She  was  sinking  then, 
and  died  at  8  a.m.  on  the  morning  of  the  23d. 

Twelve  hours  after  death  I  made  a  post-mortem  examination, 
with  the  kind  assistance  of  Mr.  Lorraine  and  Mr.  J.  Kemp. 
The  wound  made  to  relieve  the  strangulation  had  healed  by  first 
intention.  On  opening  the  abdomen  I  found  the  small  intes- 
tines much  distended  with  flatus.  The  sac  of  the  hernia  was 
empty  and  uninjured.  On  separating  the  intestines  a  black 
gangrenous  mass  was  observed  lying  in  the  concavity  of  the 
right  ilium.  On  passing  my  hand  round  it  I  discovered  that  it 
was  a  small  ovarian  tumor,  consisting  of  two  equal-sized  cysts, 
one  of  which  was  totally  gangrenous,  and  so  soft  as  to  break  up 
with  the  most  gentle  handling,  and  discharge  into  the  cavity  a 
quantity  of  dark  fetid  serum  ;  the  other  cyst  was  partially  gan- 
grenous. The  tumor  measured  about  eleven  inches  long  and 
four  inches  in  its  greatest  diameter,  and  it  had  a  constriction 
between  the  two  cysts.  Its  base  was  slightly  glued  to  the  brim 
of  the  pelvis  ;  but,  with  this  exception,  there  was  no  peritonitis. 
The  tumor  lay  across  the  transverse  diameter  of  the  pelvis,  the 
left  end  being  buried  in  the  pelvis,  while  the  right  lay  over  the 
brim  on  to  the  ilium.  It  was  the  right-hand  cyst  which  was 
totally  gangrenous. 

When  I  passed  my  hand  down  the  pedicle  I  found  that  it  was 
long  and  thin,  and  twisted  on  itself,  feeling  more  like  an  injected 
umbilical  cord  than  anything  else  with  which  I  am  acquainted. 


298  DISEASES   OF   THE    OVAKIES. 

I  remarked  to  my  colleagues  that  the  pedicle  was  twisted, 
and,  keeping  it  in  my  left  hand,  with  my  right  I  slowly  un- 
twisted it,  by  rotating  the  tumor  until  the  pedicle  was  straight. 
To  do  this,  I  had  to  alter  my  grasp  of  the  tumor  nine  times ; 
that  is,  the  pedicle  had  been  twisted  by  four  and  a  half  revolu- 
tions of  the  tumor.  It  was  the  right  ovary  which  was  diseased 
(and  the  twisting  was  from  within  outward  toward  the  right 
side,  as  far  as  my  recollection  now  serves  me). 

Concerning  this  case,  I  have  ever  since  had  a  suspicion  that 
my  operation  for  hernia  was  an  unnecessary  one,  and  that  all 
the  symptoms  were  really  due  to  the  gangrenous  tumor.  If  this 
were  really  so,  I  have  the  consolation  that  I  did  my  patient  no 
harm. 

When  this  case  came  under  my  care  I  had  never  heard  of 
the  accident,  indeed  it  occurred  nearly  twelve  years  ago,  and 
my  experience  of  ovarian  tumors  was  somewhat  more  limited 
than  it  is  now.  It  made  a  deep  impression  on  me,  however,  and 
I  resolved  if  ever  I  met  with  such  symptoms  in  another  woman, 
and  could  discover  the  presence  of  a  tumor,  I  should  not  hesitate 
to  attempt  its  removal.  This  determination  I  have  been  able  to 
carry  into  effect  on  nine  occasions  with  perfectly  successful 
results.  Of  course,  I  cannot  but  regret  that  I  did  not  recognize 
the  existence  of  this  tumor  when  I  had  the  patient  under  chloro- 
form, as  I  think  I  could  do  now  with  my  larger  experience  in 
abdominal  surgery,  though,  perhaps,  my  youth  and  inexperience 
at  the  time  form  a  barely  sufficient  apology. 

The  next  case  I  find  on  record  is  one  published  by  Dr.  Barnes 
in  aS'^.  Thomas's  Hospital  Reports  for  1870,  where  Mr.  Spencer 
Wells,  Dr.  Tyler  Smith,  and  Dr.  Oldham  had  all  recognized  the 
presence  of  an  ovarian  tumor.  Dr.  Barnes  saw  her  on  August 
26th,  and  on  September  2d,  when  the  diagnosis  of  pregnancy,  in 
addition,  was  made.  On  the  25th  there  were  all  the  indications 
of  mischief  in  the  cyst,  and  Dr.  Barnes  discussed  the  question, 
"Has  the  extra-uterine  cyst  ruptured?"  On  that  day  a  prema- 
ture foetus  was  expelled,  and  she  lingered  on  till  October  4th 
without  any  attempt  at  surgical  interference. 

At  the  post-mortem  "a  cyst  came  into  view,  dark-colored, 
stained  with  blood  in  several  points,  having  extravasated  blood 
clotted  in  its  walls.  In  places  it  was  found  very  fragile ;  it  had 
twisted  twice  axially  from  right  to  left  during  life." 

I  do  not  think  there  can  be  a  doubt  that  if  this  case  had  been 
operated  upon,  as  it  might  have  been,  seeing  the  tumor  had  been 
recogniz(>d,  the  patient  would  have  recovered. 

A  still  more  curious  case  is  related  by  Dr.  Barnes  in  the 


OVARIOTOMY.  299 

same  paper,  where  the  symptoms  of  strangulation  were  taken 
for  those  of  labor,  and  where,  on  post-mortem  examination,  he 
says  he  found  an  ovarian  tumor  entirely  free  from  adhesions, 
with  its  pedicle  twisted  twice  into  a  rope,  the  appearances  of 
gangrene  being  conclusive.  Such  a  case  would  be  just  such  a 
one  in  which  ovariotomy  would  be,  and  has  been  in  my  hands, 
successful. 

At  a  meeting  of  the  Dublin  Pathological  Society,  December 
4,  1879,  Dr.  Kidd  showed  the  preparation  from  a  woman  whom 
he  had  had  under  his  care  in  the  Coombe  Hospital,  and  who 
had  died  under  circumstances  which  clearly  pointed  to  some- 
thing wrong  in  a  tumor  which  had  been  recognized  some 
months  before.  The  preparation  was  that  of  an  uncomplicated 
ovarian  tumor,  with  twisted  pedicle  and  consequent  gangrene. 
"There  was  a  complete  turn  upon  the  pedicle  ;  this  had  strangu- 
lated the  tumor,  and  thus  gave  rise  to  the  black  appearance, 
and  the  woman  died  from  irritative  fever,  produced  by  strangu- 
lation and  sphacelation  of  the  morbid  growth."  This  is  another 
case  where  I  think  there  is  cause  for  regret  that  an  attempt  at 
removing  the  tumor  was  not  made.  From  the  experience  I  am 
about  to  give  of  my  own  practice,  I  think  there  can  be  little 
doubt  that  the  rule  will  be  established  that  if  the  existence  of 
an  ovarian  tumor  has  been,  or  can  be  recognized,  and  symptoms 
should  set  in  which  are  of  a  serious  kind,  and  can  be  referred 
to  strangulation  of  that  tumor,  an  exploratory  incision  should 
be  made,  and  the  tumor  removed  if  possible,  especially  if  it  be 
found  to  be  the  seat  of  the  mischief. 

During  1879  I  had  the  remarkable  occurrence  in  my  practice 
of  three  cases  of  gangrene  of  ovarian  or  parovarian  tumors,  due 
to  axial  rotation. 

The  first  case  was  sent  to  me  by  Dr.  Faussett,  of  Tamworth. 
She  was  forty-six  years  of  age,  her  last  confinement  was  four 
years  before,  and  her  menstruation  was  normal.  I  saw  her  first 
in  March  last  on  account  of  a  small  tumor,  which  I  diagnosed 
to  be  monocystic,  and  probably  parovarian.  I  advised  her  to 
defer  any  operation  till  it  was  larger.  She  returned  on  June  9th 
with  the  tumor  greatly  enlarged,  and  suffering  from  intense 
abdominal  pain.  Her  face  had  a  peculiar  anxious  expression, 
and  her  temperature  rose  to  39°  C.  at  night.  I  therefore  recom- 
mended the  immediate  removal  of  the  tumor.  On  opening  the 
abdomen  I  found  the  cyst  of  a  black  pearly  color,  universally 
adherent  by  recent  lymph,  its  contents  quite  black,  and  its  walls 
black,  gangrenous,  and  in  places  quite  rotten.  The  pedicle  was 
twisted  three  or  four  times,  and  at  the  point  of  maximum  con- 
striction it  was  only  as  thick  as  an  artist's  pencil.     I  tied  it  just 


300  DISEASES    OF   THE    OVARIES. 

below  this  point.  After  the  operation  she  had  no  pain,  the 
temperature  never  rose  above  3?°  C,  and  she  made  an  uninter- 
rupted recovery.  The  right,  ^ vary  was  involved  in  the  gangrene, 
but  it  was  free  from  the  tumor.  The  rotation  had  occurred 
from  within  outward  to  the  right.  The  operation  was  per- 
formed without  any  of  the  Listerian  antiseptic  precautions. 

The  second  case  occurred  in  a  patient  from  Sheffield,  placed 
under  my  care  by  my  colleague,  Dr.  Edginton.  She  was  thirty 
years  of  age,  had  been  married  ten  years,  but  had  never  been 
pregnant. 

She  had  noticed  a  gradual  increase  in  size  for  nine  months 
previous  to  my  seeing  her.  Sudden  and  violent  pain  in  the 
abdomen  occurred  on  the  4th  of  November,  followed  by  inces- 
sant sickness.  When  I  saw  lier  on  the  11th  the  diagnosis  of  an 
ovarian  tumor  was  simple,  and  her  anxious  appearance,  the 
green  sickness,  feeble  pulse,  and  the  intense  pain,  all  pointed 
to  the  probability  of  strangulation  of  the  tumor.  I  therefore 
admitted  her  at  once  to  the  hospital,  and  removed  the  tumor 
next  day.  It  was  found  to  be  uniformly  adherent  to  all  the  tis- 
sues in  contact  with  it,  the  adhesions  being  recent  and  easily 
overcome,  but  they  gave  a  great  deal  of  trouble  from  free  and 
abundant  hemorrhage.  This  was  controlled  chiefly  by  the 
application  of  solid  perchloride  of  iron  to  the  bleeding  points. 
The  tumor  itself  was  a  multilocular  cyst  of  the  right  ovary,  of 
a  uniformly  dark  purple  color,  extremely  friable,  having  large 
extravasations  of  blood  in  the  walls,  and  especially  at  the  base, 
close  to  the  pedicle.  The  pedicle  was  very  short,  and  was 
twisted  twice  completely  round,  from  within  outward  and  to 
the  right.  The  operation  was  performed  with  complete  antisep- 
tic precautions,  but  the  temperature  and  pulse  curves  show  that 
she  made  anything  but  an  antiseptic  recovery.  The  pedicle 
was  secured  by  the  Staffordshire  knot.  She  left  the  hospital  on 
December  14,  1879. 

The  next  case  occurred  immediately  after  that  just  narrated. 
She  was  thirty-six  years  of  age,  had  had  children,  the  last  four 
years  ago.  She  had  not  menstruated  for  seventeen  weeks,  but 
had  noticed  an  increase  of  size  so  rapid  that  it  could  not  be  ex- 
plained by  ordinary  pregnancy.  I  saw  her  for  the  first  time  on 
November  10th  at  the  out-patient  department,  and  though  the 
diagnosis  was  difficult  on  account  of  the  patient  being  very  fat, 
I  made  out  early  pregnancy  and  an  ovarian  tumor. 

She  came  back  on  November  23d  complaining  of  intense 
abdominal  pain,  which  had  come  on  suddenly  two  days  before, 
followed  by  incessant  sickness.  Slio  looked  very  ill,  and  vom- 
ited green  matter  while  in  the  consulting-room.     I  at  once  sent 


OVARIOTOMY.  301 

her  into  the  hospital  and  called  an  emergency  consultation  with 
my  colleague,  Dr.  Savage.  He  agreed  with  me  that  it  was  a 
case  of  pregnancy,  with  a  strangulated  cyst,  the  only  argument 
against  this  view  being  the  apparent  absurdity  of  my  having 
two  such  cases  in  the  hospital  at  the  same  time,  and  the  likeli- 
hood that  our  recent  experience  should  lead  us  into  too  ready  a 
diagnosis.  However,  we  stuck  to  our  view,  and  agreed  upon 
immediate  operation.  This  I  performed,  and  found  the  case  to 
be  exactly  as  I  had  diagnosed.  The  uterus  was  occupied  by  a 
pregnancy  of  about  the  fourth  month,  and  the  tumor  was  a  par- 
ovarian cyst  of  the  right  side,  of  a  pearly  black  lustre,  the  ovary 
lying  on  its  front  in  the  line  of  incision,  at  least  ten  times  as 
large  as  an  ordinary  ovary,  being  four  inches  long  and  two 
broad,  the  enlargement  being  due  entirely  to  extravasation  of 
blood  in  its  tissue.  The  Fallopian  tube  stretched  over  about  a 
third  of  the  circumference  of  the  tumor,  running  down  toward 
its  twisted  pedicle,  of  which  it  formed  part.  In  the  wall  of  the 
tumor,  and  especially  at  its  base,  were  effusions  of  blood.  The 
contents  of  the  tumor  were  straw-colored,  but  viscid.  The 
tumor  had  made  three  complete  revolutions  from  within  out- 
ward and  to  the  right  side.  There  were  no  adhesions,  and  the 
operation  presented  no  difficulty,  and  it  was  carried  out  with 
complete  Listerian  antiseptic  precautions.  She  made  a  better 
recovery  than  the  second  case,  but  not  so  good  as  the  first,  to 
which  it  really  had  a  very  close  resemblance.  No  symptoms  of 
miscarriage  showed  themselves.  She  left  the  hospital  on  De- 
cember 21st,  and  her  pregnancy  was  satisfactorily  terminated. 

One  feature  which  was  characteristic  of  all  three  of  these 
cases,  and  which  I  have  omitted  to  mention  in  connection  with 
the  second,  is  that  the  abdomen  undergoes  a  very  rapid  and  un- 
usual increase  in  size  for  a  few  days  before,  or  coincident  with, 
tlie  access  of  the  violent  pain.  In  two  it  was  noticed  to  have 
occurred  to  a  marked  degree  before  pain  was  felt,  and  this  we 
may  easily  believe  to  be  the  stage  of  strangulation  productive 
of  cedema  and  precedent  to  that  of  gangrene.  This  points  to 
the  conclusion  that  the  rotation  is  gradual.  I  have  had  six  other 
cases  in  all  of  which  the  leading  features  were  identical  with 
those  narrated. 

The  symptoms  recorded  in  all  these  cases  are  closely  alike. 
The  chief  feature  is  the  sudden  accession  of  severe  abdominal 
pa:ln  and  tenderness,  followed  immediately  by  vomiting,  which 
soon  becomes  green.  The  pulse  rises,  but  the  temperature  does 
not  always  do  so.  These  symptoms  in  the  recognized  presence 
of  an  abdominal  tumor  which  may  be  ovarian,  should  lead  at 
once  to  abdominal  section,  and  they  would  do  so  in  my  practice, 


802  DISEASES   OF   THE   OVARIES. 

whether  the  tumor  were  ovarian  or  not,  if  there  seemed  to  be 
any  probabilit}^  of  its  being  possible  to  remove  it. 

As  to  the  mechanism  by  which  this  singular  rotation  is  pro- 
duced, we  may  at  once  dismiss  any  explanation  which  attributes 
it  to  the  condition  of  the  tumors  themselves,  for  we  find  it  occur- 
ring in  tumors  of  all  kinds,  large,  small,  smooth,  and  globular, 
multicystic  and  irregular,  parovarian,  ovarian,  dermoid,  and 
solid  fibrous  tumors,  the  only  intrinsic  conditions  of  the  tumors 
being  that  they  should  be  free  to  move,  and  have  pedicles  capa- 
ble of  being  twisted. 

Unfortunately,  in  the  majority,  or  at  least  in  a  very  large 
number,  of  the  cases,  the  direction  of  the  twist  is  not  clearly 
stated,  or  not  given  at  all,  nor  is  the  side  on  which  the  tumor 
grew  clearly  given. 

Of  the  cases  narrated  by  Rokitansky,  the  great  majority, 
about  four-fifths,  were  tumors  of  the  right  side,  and  in  a  still 
larger  proportion  the  twist  was  from  the  left  to  the  right  side — 
that  is,  taking  the  vertebral  column  as  the  starting-point,  the 
twist  travelled  to  the  left  side,  and  then  forward  and  over  to  the 
right,  that  being  what  I  read  as  his  "  und  ebenso  kommt  die 
Drehung  nach  aussen  weitans  haufiger  vor,  als  jene  nach  in- 
nen,"  though  it  is  by  no  means  certain  that  my  rendering  is  cor- 
rect. 

Certainly,  in  all  of  my  own  cases  the  tumor  was  on  the  right 
side,  and  the  twisting  in  all  those  operated  upon  was  as  I  have 
just  described,  and  in  the  first  case  I  have  given  my  recollection 
as  that  it  was  in  this  direction  also.  It  is  not  recorded  so  in  my 
notes,  however,  and  my  memory  may  be  in  error,  though  I 
think  it  is  likely  to  be  correct,  as  the  case  made  a  more  profound 
impression  on  my  mind  than,  perhaps,  any  other  incident  in  my 
surgical  experience. 

If  we  had  exact  statements  on  these  points  for  a  large  number 
of  cases,  I  think  we  might  arrive  at  some  conclusion  as  to  the 
cause  of  the  rotation. 

In  a  few  of  the  isolated  cases  explanations  are  given  which 
seemed  more  or  less  possible  to  the  narrators,  but  they  do  not 
bear  the  examination  of  extended  experience.  To  two  of  these 
I  have  already  alluded,  and  only  a  third  requires  to  be  men- 
tioned. Dr.  Barnes  hazards  the  explanation  that  "  the  tumor 
being  free  from  adhesions,  and  tolerably  firm,  may  roll  over  on 
its  axis.  This  may  happen  from  the  enlargement  of  the  uterus 
tilting  it  over,  or  from  over-exertion,  when,  one  part  of  the 
tumor  being  more  pressed  upon  than  the  opposite  part,  it  rolls 
over."  The  part  of  this  explanation  wiiich  applies  to  cases  where 
the  rotation  occurs  in  association  with  a  pregnant  uterus  applies 


OVARIOTOMY.  303 

only  to  a  small  number  of  the  cases,  even  if  ifc  were  sufficient, 
which  I  do  not  think  it  is,  and  therefore  may  be  dismissed.  The 
rest  of  the  explanation  simply  amounts  to  a  rejjetition  of  the  fact 
that  this  singular  phenomenon  does  occur,  and  is  no  explanation 
at  all. 

The  only  reasonable  effort  to  explain  the  incident  has  been 
made  by  Klob,  who  has  made  some  experiments,  from  which  he 
concludes  that  it  is  the  alternate  filling  and  evacuation  of  the 
bladder  which  rotates  the  tumor.  I  have  not  been  able  to  find 
the  original  paper,  and  am,  therefore,  unable  to  criticise  the  basis 
of  his  opinion,  but  on  a  prior-i  grounds  I  think  there  may  be 
something  in  his  idea.  But  before  I  knew  of  this  explanation, 
and  entirely  from  my  own  cases,  I  had  come  to  the  conclusion 
that  it  was  the  alternant  filling  and  emptying  of  the  rectum 
which  caused  the  rotation,  and  it  is  possible  enough  that  the 
bladder  may  help.  That  the  bladder  alone  should  do  it  is,  I 
think,  unlikely,  for  being  central  its  influence  would  be,  in  all 
probability,  neutral.  If  it  were  the  rectum,  then  this  force  act- 
ing on  the  left  side  of  the  point  of  rest,  the  vertebral  column, 
would  inevitably  push  the  tumor  in  the  direction  in  which,  in  at 
least  nine  out  of  ten  of  my  cases,  the  movement  took  place  ; 
and  it  would  certainly  act  more  readily  on  right-side  tumors  than 
on  those  of  the  left  side,  for  the  former  are  anchored  so  that 
the  pushing  force  of  the  rectum  will  be  in  the  requisite  oblique 
direction,  in  the  plane  of  a  screw,  and  very  nearly  at  right  an- 
gles to  the  axis  of  movement. 

If  I  might  venture  to  apply  a  dynamical  illustration  to  path- 
ology, I  would  say  that  an  ovarian  tumor  growing  on  the  right 
side  with  a  free  pedicle,  and  resting,  therefore,  with  its  axis  in- 
clined toward  the  top  of  the  ninth  or  tenth  rib  on  the  left  side, 
would  be  in  the  condition  of  a  body  having  freedom  of  the  first 
order — that  is,  free  to  rotate  about  a  fixed  axis,  but  not  to  slide 
along  it.  To  such  a  body  a  screw,  in  the  form  of  a  wedge,  would 
be  applied  by  the  rectum  in  the  most  favorable  of  all  directions, 
in  a  direction  obliquely  from  above  downward,  across  the  axis  of 
freedom  and  below  the  equator  of  the  moving  body.  Every 
piece  of  faeces  which  passed  into  the  rectum,  especially  in  the  re- 
cumbent position  of  the  patient,  would  act  as  a  wedge  to  drive 
the  tumor  round.  In  obedience  to  the  dynamic  law,  that  by  a 
successive  repetition  of  the  process  an  indefinite  quantity  of  en- 
ergy may  be  produced,  however  small  the  initial  force  may  be,  we 
have  at  once  the  explanation  of  the  phenomena  of  many  of  these 
cases,  notably  of  that  published  by  Mr.  Thornton,  We  have,  in 
fact,  this  process  of  rotation  going  on  slowly  until  the  point  of 
strangulation  has  arrived,  when  the  sudden  access  of  pain  for 


304  DISEASES    OF   THE   OVAEIES. 

the  first  time  indicates  that  something  has  gone  wrong.  For  the 
bladder  a  similar  wedge-like  influence  may  be  claimed,  but  from 
its  want  of  obliquity,  it  is  not  likely  to  be  so  powerful  an  agent 
in  the  production  of  rotation.  Both  rectum  and  bladder  would 
act,  however,  in  the  same  direction,  and  if  it  be  found  on  further 
investigation  that  the  tumors  are  mostly  those  of  the  right  side, 
and  are  generally  twisted  in  the  direction  in  which  mine  were,  I 
think  we  may  accept  the  rectum  as  the  chief  factor. 

That  this  rotation  may  occur  suddenly,  that  is  to  say,  that  an 
ovarian  tumor  may  be  twisted  rapidly  round  two  or  three  times 
in  a  few  minutes  or  hours,  is  inconceivable. 

Rokitansky  publishes  (18G5,  ioc.  cit.)  the  post-mortem  ac- 
counts of  fifty-eight  cases  of  ovarian  tumor  in  a  period  of  four 
years,  and  in  eight  of  these  rotation  of  the  tumor  had  occurred, 
but  in  four  only  did  it  seem  to  have  given  rise  to  strangulation 
and  death.  Rotation  is,  therefore,  frequent,  as  Rokitansky  says, 
occurring  in  about  twelve  per  cent,  of  all  cases,  and  in  about  six 
per  cent,  of  all  cases  producing  death.  My  own  proportion  is 
not  nearly  so  high,  my  first  hundred  ovariotomies  including 
only  one  of  my  cases,  and  in  the  practice  of  other  ovariotomists 
we  have  not  as  yet  heard  much  of  gangrene  from  rotation. 

The  greater  part  of  what  I  have  just  said  on  this  interesting  sub- 
ject is  taken  from  a  paper  which  was  read  before  the  Obstetrical 
Society  of  London  last  year.  In  the  discussion  which  followed, 
my  theory  of  the  cause  of  axial  rotation  received  very  material 
confirmation  from  Mr.  Alban  Doran,  who  said  that  it  accorded 
with  some  of  his  own  convictions  grounded  on  experiments  he 
had  made  in  the  postmortem  room  of  the  Samaritan  Hospital 
when  examining  cases  of  ovarian  disease  that  had  proved  fatal 
before  any  operation  could  be  performed.  Supposing  that  a  largo 
tumor  with  an  irregular  surface  lay  to  the  right  of  the  rectum, 
an  accumulation  of  faeces  might  press  upon  the  pelvic  portion  of 
the  growth  in  such  a  manner  as  to  push  the  whole  tumor  about 
a  quarter  of  a  turn  round  its  vertical  axis.  Should  the  pedicle 
be  very  long,  or  short,  yet  inelastic,  it  would  remain  twisted  after 
this  pressure  was  removed,  and  might  become  still  more  twisted 
after  it  was  reapplied.  Should  the  pedicle  be  short  and  elastic, 
the  tumor  would  slip  back  to  its  normal  position  every  time  that 
the  pressure  was  removed  ;  only  this  pressure  might  be  applied  so 
long  that  the  temporary  torsion  might  involve  damage  to  the 
vessels  of  the  pedicle,  producing  all  the  bad  effects  of  permanent 
and  complete  torsion  after  the  pedicle  has  become  untwisted. 
In  examining  the  body  of  a  patient  who  died  in  Mr.  Xnowsley 
Thornton's  ward  last  December  ho  found  a  large  ov£.,rian  tumor 
pressed  upon  to  the  left  side,  interiorly,  by  the  rectum,  which 


OVARIOTOMY.  306 

was  slightly  distended  owing  to  a  cancerous  stricture.  A  little 
artificial  distention  of  the  intestine  caused  it  to  press  against  the 
tumor  so  as  to  push  its  left  side  backward,  stretching  and  twist- 
ing the  pedicle.  In  examining  this  pedicle  he  found  that  it  was 
not  twisted,  but  that  its  veins  were  partially  plugged,  in  all  prob- 
ability from  the  effects  of  intermittent  pressure  through  fre- 
quent extreme  distention  of  the  obstructed  rectum. 

Mr.  Wells  suggested  that  the  rotation  was  little  more  than  an 
accident,  but  an  accident  of  such  frequent  occurrence  must  have 
some  kind  of  uniform  cause  ;  and  if  it  be  true  generally,  as  it  cer- 
tainly was  in  Rokitansky's  observations  and  in  my  own,  that  the 
great  majority  of  the  tumors  twisted  were  right-sided  tumors,  and 
that  they  were  twisted  in  one  specific  direction,  it  is  clear  that 
some  special  mechanism  must  be  concerned  in  the  process  of  ro- 
tation. The  facts  given  by  Mr.  Alban  Doran  are  emphatically  in 
favor  of  the  theory  I  have  advanced,  and,  doubtless,  if  Mr.  Doran 
continues  his  observations,  some  valuable  results  will  be  arrived 
at.  If  a  left-sided  tumor  could  be  found  rotated  from  within 
outward  and  over  to  the  left,  in  a  case  where  the  rectum  was  on 
the  right  side,  I  should  regard  my  hypothesis  as  proved. 

Rokitansky  says  that,  as  one  of  the  results  of  this  rotation 
and  strangulation  of  ovarian  tumors,  we  may  get  involution  and 
wasting  of  the  growth,  so  that  in  many  cases  they  may  diminish 
and  disappear ;  and  Mr.  Wells,  quoting  Rokitansky,  seems  to 
agree  with  him. 

There  is  reason  to  believe  that  sometimes  this  axial  rotation 
succeeds  in  destroying  the  pedicle  altogether,  and  separating  the 
tumor  from  its  connection,  one  might  imagine  a  tumor  possibly 
being  quite  cured  in  this  way.  Dr.  Peaslee  {American  Journal 
of  Obstetrics,  1878)  mentions  a  case  of  an  ovarian  tumor  detached 
from  its  pedicle,  in  which,  from  the  history,  I  believe  it  likely 
that  the  detachment  was  effected  by  axial  rotation.  Dr.  Peaslee 
says:  "  After  the  tumor  had  grown  about  two  years,  it  ceased 
growing  entirely  for  six  or  eight  years,  then  it  began  to  grow 
again.  It  was  very  singular  that  he  could  find  no  connection 
between  the  first  cessation  of  growth  and  the  second  accession. 
It  was  thought  by  her  friends  that  she  had  hernia,  for  there  was 
great  suffering,  referable  to  the  inguinal  region.  It  kept  her  in 
bed  some  time.  After  she  got  up,  the  tumor  grew  no  more. 
At  the  operation  the  omentum  was  found  to  be  quite  exten- 
sively adherent,  and  there  was  near  it  an  artery  of  peculiar 
development,  about  the  size  of  the  brachial  artery,  which 
divided  into  a  great  many  branches.  Upon  putting  his  hand 
into  the  cavity,  he  found  that  he  could  run  it  all  around  the 
tumor  ;  he  found  no  pedicle  whatever  ;  all  the  attachment  it  had 
20 


306  DISEASES   OF   THE   OVARIES. 

was  that  referred  to  above.  He  then  proceeded  to  ligate  the 
vessels  and  removed  the  tumor.  He  found  it  to  present  all  the 
characteristics  of  an  ovarian  cyst;  there  could  be  no  doubt  as 
to  what  it  was.  There  was  a  notch  in  the  broad  ligament,  show- 
ing that,  at  the  time  of  the  attack,  there  had  been  a  pedicle.  It 
had  become  twisted  around  and  around,  so  that  the  circulation 
had  been  cut  off,  and  it  ceased  growing.  It  had  been  nour- 
ished, no  doubt,  from  contact,  from  which  circumstance  this 
series  of  larger  vessels  had  sprung  up,  the  vessels  being  larger 
in  proportion  as  necessity  required." 

Besides  the  acute  symptoms  which  are  induced  by  the  stran- 
gulation of  an  ovarian  or  parovarian  tumor,  we  may  have  a 
condition  of  equal  severity  arising  from  peritonitis  or  from  sup- 
puration of  the  cyst.  I  have  on  seven  occasions  been  obliged  to 
remove  tumors  at  a  very  few  hours'  notice,  when  summoned 
to  patients  suffering  from  acute  peritonitis.  Of  these  seven, 
six  made  excellent  recoveries,  all  the  symptoms  disappearing 
in  a  few  hours  after  the  operation.  The  fourth  case  was  one 
which  occurred  in  my  early  practice,  when  I  used  the  clamp, 
and  from  this  cause  the  patient  died.  From  the  results  obtained 
by  the  immediate  removal  of  tumors  when  there  is  peritonitis, 
in  th«  hands  of  Dr.  Keith,  Mr,  Spencer  Wells,  Mr.  Pridgin  Teale, 
of  Leeds,  and  others,  the  rule  has  become  quite  established  to 
operate  without  delay  when  there  is  this  complication. 

Suppuration  of  a  tumor  is  not  unfrequently  met  with.  Usu- 
ally it  is  the  result  of  tapping,  but  I  have  seen  it  occur  without 
any  ascertainable  cause.  The  symptoms  are  not  generally  so 
pronounced  as  they  are  in  peritonitis,  but  they  are  always  suffi- 
ciently severe  to  attract  attention,  and  to  give  rise  to  a  suspi- 
cion of  the  actual  state  of  matters.  When  there  is  reason  to 
believe  that  so  grave  an  accident  has  occurred,  immediate  re- 
moval of  the  tumor  is  the  correct  practice,  more  particularly  if 
the  symptoms  have  occurred  after  tapping.  In  such  cases,  of 
course,  the  cleansing  of  the  peritoneum  must,  if  possible,  be  made 
with  even  greater  care  than  in  any  others,  and  I  think  that 
probably  in  cases  where  there  is  pus  in  the  peritoneum,  drain- 
age after  the  plan  of  Koeberle  and  Keith  will  conduce  to  the 
recovery  of  the  patient. 

Dr.  Keith  was  the  first  to  set  the  example  of  removing  an 
ovarian  tumor  under  these  desperate  circumstances.  His  first 
case  was  in  December,  1804,  and  was  successful.  He  tells  us 
(Edinburgh  3  fedicalJoiwnal,  1875)  :  "  Since  then  I  have  ten  times 
met  with  cases  of  acute  suppurating  cysts,  besides  two  chronic 
cases.  In  all  of  these,  save  one,  the  chance  of  ovariotomy  was 
given,  however  hopeless-looking  the  case  might  be." 


OVARIOTOMY.  307 

After  the  performance  of  an  ovariotomy,  and  after  the  pa- 
tient has  recovered  from  the  effects  of  the  anaesthetic,  the  first 
symptom  we  have  to  deal  witli  is,  as  a  rule,  sickness,  and 
sometimes  it  is  extremely  distressing.  It  is  due,  in  the  first 
instance,  to  the  anaesthetic.  During  my  earlier  experience  I 
was  under  the  belief  that  the  use  of  ether  was  more  seldom  fol- 
lowed by  sickness  than  was  the  use  of  any  other  anaesthetic, 
but  I  must  now  say  I  do  not  think  ether  possesses  any  great 
advantage  in  this  respect ;  but  as  I  do  not  find  patients  suffer  so 
much  from  ether  sickness  after  other  operations  as  they  do  after 
ovariotomy,  I  am  inclined  to  believe  the  constriction  of  the  pedi- 
cle has  something  to  do  with  the  vomiting  as  well  as  the  ether. 
Whatever  be  the  cause,  it  is  certain  that  in  a  good  many  of  my 
operations  there  is  a  deal  of  trouble  with  sickness,  sometimes 
lasting  as  long  as  twenty-four  or  twenty-five  hours.  I  have  tried 
a  great  many  means  of  arresting  this  ugly  symptom,  and  by  far 
the  most  effectual  I  find  to  be  the  administration  of  tepid  water, 
slightly  flavored  with  brandy.  I  never  now  use  ice  for  this 
purpose,  as  I  have  not  found  it  very  efiicacious.  It  gives  rise 
to  intolerable  thirst,  and  this  is  altogether  avoided  by  the  use  of 
tepid  water.  Should  there  be  any  pain  after  the  operation,  I 
direct  the  use  of  a  suppository  containing  one-fourth  of  a  grain 
of  morphia,  but  with  this  agent  I  am  extremely  cautious,  for 
my  patients  never  get  a  single  dose  of  morphia  or  opium  more 
than  is  absolutely  necessary  to  relieve  pain.  Like  other  opera- 
tors, I  have  long  since  discarded  the  routine  use  of  opium,  which 
.was  the  fashion  at  one  time,  a  practice  brought  into  existence 
by  the  idea  that  it  prevented  the  occurrence  of  peritonitis.  With 
my  patients  as  little  as  f)ossible  is  done  in  the  after  treatment, 
each  symptom  being  dealt  with  only  as  it  arises,  and  it  is  quite 
exceptional  for  me  to  have  to  subject  them  to  any  active  inter- 
ference. 

The  ice  cap  seems  to  be  in  very  constant  use  at  the  Samari- 
tan Hospital,  but  I  have  never  yet  employed  it.  We  hear  of 
some  thousands  of  pounds  of  ice  being  used  every  year  for  it, 
and  I  have  been  told  that  a  large  cistern  has  been  erected  at  the 
top  of  the  hospital,  with  pipes  distributed  all  over  the  building, 
for  the  purpose  of  supplying  iced  water  to  the  patients'  heads. 
Dr.  Bantock's  explanation  of  this  is  to  the  effect  that  it  is  necessi- 
tated by  the  amount  of  carbolic  acid  used  in  some  of  the  opera- 
tions. In  my  own  practice  I  have  never  seen  cases  of  exaltation 
of  temperature,  except  in  cases  where  the  Listerian  details 
were  fully  carried  out,  or  where  the  clamp  was  used.  It  never 
seemed  to  me  that  the  use  of  the  ice  cap  was  at  all  a  rational 
proceeding,  but  whether  I  am  or  am  not  correct  on  this  point  is 


308  DISEASES   OF   THE   OVARIES. 

not  a  matter  of  much  importance.  I  have  never  used  it  and  my 
mortality  is  much  smaller  than  the  mortality  where  the  ice  cap 
is  used. 

When  from  some  reason  or  another  the  patients  begin  to  do 
badly,  the  first  indication  is  an  altered  expression  of  the  face. 
I  am  unable  to  describe  this  change  of  countenance,  but  I 
learned  to  recognize  it  only  too  well  in  the  old  days  when,  from 
the  use  of  the  clamp,  my  mortality  ran  high.  Associated  with 
this  changed  expression  is  a  rapidly  increasing  abdominal  dis- 
tention, speedily  followed  by  vomiting.  At  first  the  vomited 
matter  is  simply  the  fluid  the  patient  has  swallowed,  but  soon  it 
becomes  tinged  with  bile.  Later  on,  should  the  patient  grow 
worse,  the  vomited  matter  becomes  entirely  bilious,  and  toward 
the  end  it  gets  quite  black  and  characterized  by  these  features 
to  which  the  name  of  "  coffee  ground"  vomiting  has  been  aptly 
given.  In  those  instances  where  death  followed  the  use  of  the 
clamp,  the  phenomena  always  began  on  the  second  or  third  day, 
the  patient  dying  on  the  fourth  or  fifth  ;  and  when  once  these 
fatal  symptoms  had  become  fairly  established,  nothing  I  ever 
did  could  arrest  them.  To  recapitulate  here  the  therapeutic 
experiments  based  upon  all  kinds  of  hints,  derived  from  reading 
and  from  the  advice  of  friends,  would  be  perfectly  needless,  for 
in  not  a  single  instance  did  I  ever  see  beneficial  effects  from  any 
of  them. 

On  opening  the  abdomen  after  death  the  uniform  appearances 
were  found  to  be  those  of  diffuse  suppurative  peritonitis.  It 
was  impossible  to  trace  in  every  instance  the  exact  cause  of 
death,  yet  sufficient  evidence  was  obtained  to  make  me  attribute 
the  fatal  result  in  such  cases  to  the  presence  of  a  minute  aper- 
ture in  the  wound,  at  the  point  where  the  pedicle  was  embraced, 
through  which  the  discharges  from  the  ulcerated  surface  under 
the  clamp  penetrated  into  the  abdominal  cavity.  With  the 
discontinuance  of  the  clamp  such  cases  as  these  have  entirely 
disappeared,  and  now  not  only  is  it  quite  exceptional  to  have  a 
fatal  case,  but  it  is  quite  unusual  to  have  any  anxiety  concerning 
my  patients'  recovery.  Sometimes  bilious  vomiting  occurs,  why 
I  hardly  know.  I  cannot  think  this  a  very  dangerous  symptom, 
for  I  can  recall  but  one  instance  of  its  being  so  persistent  as  to 
give  rise  to  anxiety.  As  soon  as  the  vomited  matter  shows 
signs  of  bile,  I  give  some  mild  laxative,  generally  a  seidlitz 
powder  or  a  teaspoonf ul  of  Epsom  salts,  and  a  small  dose  of  calo- 
mel, and  the  symptom  is  speedily  brought  to  an  end. 

With  reference  to  movement  of  the  bowels  after  an  abdom- 
inal operation,  I  have  entirely  lost  all  the  fears  derived  from 
tradition,  and  I  never  take  any  steps  to  prevent  their  ordinary 


OVARIOTOMY.  309 

motion,  indeed  the  administration  of  laxatives  within  a  few 
hours  after  the  operation  is  becoming  quite  a  common  practice 
with  me,  this  innovation,  in  my  opinion,  being  possibly  conducive 
in  some  measure  to  my  increased  success. 

Concerning  fatal  cases  I  am  altogether  of  Dr.  Keith's  opin- 
ion, that  the  very  first  search  to  be  made  for  an  explanation 
should  be  in  the  details  of  the  operation,  and  every  fatal  case 
occurring  to  me  is  subjected  to  most  rigorous  inquiry.  Some- 
times I  have  found  reason  to  suspect  some  omission  or  commis- 
sion on  my  own  part ;  in  others  I  thought  the  surroundings 
were  at  fault ;  while  in  other  instances  I  have  been  totally  un- 
able to  account  for  the  catastrophe.  Two  of  my  fatal  cases, 
where  the  ligature  had  been  used,  were  due  to  intestinal  obstruc- 
tion, and  this  arose  from  a  kind  of  paralysis  of  the  intestines 
which  was  perfectly  inexplicable.  Dr.  Battey  tells  me  he  has 
seen  the  same  thing.  In  both  instances  the  patients  had  made 
satisfactory  progress  until  the  sixth  day  after  the  operation, 
without  the  slightest  interruption,  when  suddenly  the  abdomen 
became  greatly  distended,  incessant  vomiting  occurred,  and  the 
patients  rapidly  sank.  After  death  nothing  could  be  found  ex- 
cept enormous  distention  of  the  abdomen  by  fluid  fseces  and 
gases.  In  both  cases  temporary  relief  was  produced  by  tapping 
the  intestines.  The  only  explanation  I  can  offer  of  the  fatality 
in  these  cases  is  that  some  mysterious  influence,  similar,  perhaps, 
to  that  which  causes  tetanus,  brought  about  this  unexpected  and 
inexplicable  end. 

One  of  my  recent  deaths  arose  from  a  cause  which  will  serve 
to  show  how  much  care  should  be  exercised  in  watching  the  ac- 
tions of  those  who  play  less  prominent  parts  in  our  operations,  as 
well  as  in  conducting  our  own  proceedings.  A  death  had  oc- 
curred in  the  hospital  from  a  distinctly  septic  cause,  in  a  case 
under  the  charge  of  one  of  my  colleagues,  and  after  death  the 
body  was  allowed  to  remain  in  the  ward  for  an  unnecessarily 
protracted  time.  My  patient  was  placed  in  the  same  ward 
within  a  very  few  hours  afterward,  and  though  her  operation 
was  performed  with  complete  Listerian  precautions,  within  a 
very  few  hours  she  had  all  the  indications  of  acute  septic  poison- 
ing and  died  in  less  than  eighty  hours.  Unfortunately,  it  was 
not  until  after  the  accident  had  occurred  that  I  became  aware 
that  the  directions  which  up  to  that  time  had  always  been  care- 
fully carried  out,  had  in  this  instance  been  omitted.  The  les- 
sons to  be  derived  from  that  unhappy  circumstance  are  twofold: 
that  no  precaution  can  be  too  great  in  guarding  against  such  a 
catastrophe,  and  that  the  Listerian  details  cannot  be  relied  upon 
to  prevent  septic  poisoning. 


310  DISEASES    OF   THE    OVARIES. 

Dr.  Bantock  has  drawn  attention  to  a  distinct  danger  in- 
volved in  the  employment  of  carbolic  acid  after  Lister's  method, 
which  I  had  not  recognized  until  he  pointed  it  out,  but  since 
that  time  I  have  seen  three  marked  cases  of  it,  and,  looking 
back  upon  my  own  practice,  I  find  record  of  what,  I  have  very 
little  doubt,  was  a  fatal  case  of  carbolic  acid  poisoning.  What 
I  allude  to  is  the  alteration  of  the  urine,  which  is  well  known  to 
be  a  result  of  the  use  of  carbolic  acid.  Some  months  ago  I  had 
occasion  to  open  the  abdomen  of  a  child,  placed  under  my  care 
by  Dr.  Totherick,  of  Wolverhampton,  on  account  of  a  pelvic 
abscess  communicating  with  the  bladder.  The  operation  was 
performed  with  complete  Listerian  details.  Within  twelve 
hours  of  the  operation  it  was  observed  that  the  child's  urine 
possessed  the  characteristic  color  given  by  indican,  and  that  the 
small  amount  of  albumen  which  had  been  recognized  in  the 
urine  previous  to  the  operation  had  increased  to  such  an  extent 
that  the  deposit  after  the  urine  was  boiled  occupied  nearly  half 
the  tube.  Twelve  hours  after  convulsions  occurred,  and  the 
child  became  comatose.  My  colleague.  Dr.  Heslop,  whom  I 
asked  to  see  the  patient,  regarded  the  symptoms  as  perfectly 
characteristic  of  meningitis,  and  he  gave  a  prognosis  of  an  un- 
favorable kind.  I  was,  however,  strongly  impressed  with  the 
belief  that  the  child  was  suffering  from  carbolic  acid  poisoning. 
This  opinion  was,  I  think,  sustained  by  the  events,  for  the 
indican  disappeared,  the  albumen  diminished,  the  convulsions 
ceased,  the  child  regained  consciousness,  and  in  about  six  days 
after  the  operation  the  whole  train  of  symptoms  had  passed 
away.  In  another  child  upon  whom  I  did  abdominal  section  I 
saw  similar,  though  by  no  means  such  severe  symptoms,  and 
in  a  full-grown  woman  of  twenty-four  years  of  age  I  again  saw 
them  repeated.  One  of  the  first  operations  I  performed  on  the 
Listerian  method  died  in  thirty-six  hours  after  the  operation 
with  complete  suppression  of  urine;  and  my  belief  now  is  that 
she  died  of  acute  carbolic  acid  poisoning,  though,  as  I  did  not 
recognize  such  a  possibility  at  the  time,  I  am  not  prepared  to 
say  absolutely  that  it  was  so,  but  I  have  never  seen  suppression 
of  tlie  urine,  or  any  alteration  of  it,  such  as  I  witnessed  in  these 
cases,  save  where  carbolic  acid  had  been  freely  used.  Years 
ago,  when  we  used  carbolic  acid  of  the  strength  of  one  in  four  as 
the  carbolic  oil,  it  was  a  very  common  thing  indeed  to  see  seri- 
ous urinary  symptoms  associated  with  its  employment^  and  I 
am  perfectly  certain  that  a  great  many  fatal  cases  of  carbolic 
acid  poisoning  are  caused  by  the  too  free  and  even  indiscriminate 
use  of  this  poisonous  agent. 

I  have  no  very  fixed  rules  concerning  the  diet  of  my  patients 


OVARIOTOMY.  311 

recovering  from  an  ovariotomy,  save  that  as  long  as  there  is 
any  tendency  to  sickness  they  have  no  soHd  food.  But  1  do  not 
put  them  through  a  term  of  three  or  four  days  systematic  star- 
vation as  I  formerly  did.  Toward  the  end  of  the  first  or  the 
beginning  of  tlie  second  day  they  are  allowed  to  have  some 
beef-tea  or  milk.  The  first  solid  food  they  get  is  either  some 
custard  pudding,  some  dry  toast,  or  a  little  boiled  fish,  and 
these  are  cautiously  followed  by  a  little  boiled  chicken,  or,  in- 
deed, whatever  they  may  express  a  particular  fancy  for,  if  the 
preference  be  a  reasonable  one.  If  the  bowels  show  no  indica- 
tion to  move  of  their  own  accord  by  the  third  or  fourth  day,  au 
enema  is  given  and  repeated  at  intervals  until  it  has  the  desired 
effect. 

The  dressing  of  the  wound  is  limited  to  absorbent  wool  or  a 
little  zinc  ointment  if  stitch-hole  abscesses  should  form,  or 
some  of  the  old  red  lotion  if  the  wound  should  gape  anywhere. 
The  stitches  are  removed  between  the  sixth  and  eighth  days, 
and  the  patients  are  generally  up  between  the  fourteenth  and 
twenty-first. 

Before  the  patients  are  allowed  to  be  up  they  are  always  pro- 
vided with  a  well-fitting  abdominal  belt,  and  this  they  are 
earnestly  enjoined  never  to  be  without,  while  in  the  erect  posi- 
tion, for  at  least  a  year  after  the  operation.  If  this  injunction 
be  obeyed,  there  is  never  any  tendency  to  protrusion  of  the  in- 
testines ;  but  with  hospital  patients  it  is  almost  impossible  to  get 
these  orders  carried  out,  and  the  consequence  is  that  it  is  not 
unusual  to  find  them  return  in  about  three  or  four  months  with 
a  hernial  protrusion,  while  in  private  practice  this  is  almost  un- 
known. 

One  of  the  many  arguments  used  against  the  intra-peritoneal 
method  of  dealing  with  the  pedicle  was  that  the  stump  might 
contract  adhesions  to  a  loop  of  intestine  and  produce  strangula- 
tion, or  that  an  abscess  might  form  round  the  ligature  and  give 
rise  to  much  trouble.  So  far  as  I  know  the  results  of  my  prac- 
tice, in  not  a  single  instance  have  these  anticipations  been 
fulfilled.  I  direct  my  patients  to  see  me  or  write  to  me  every 
two  months  after  their  operations,  and  I  keep  a  correct  record 
of  their  visits  and  letters,  and  therefore  I  think  I  may  say  that  I 
watch  the  after-results  of  my  operations  with  exceptional  care. 

In  my  earlier  practice  I  laid  great  stress  upon  the  practice  of 
keeping  the  pelvis  quiet,  as  I  thought,  by  preventing  the  patient 
passing  water  for  herself,  and  emptying  her  bladder  every  five 
or  six  hours  regularly  by  the  catheter.  One  source  of  trouble 
which  arose  from  this  practice  was  the  frequent  occurrence  of 
cystitis,  which  in  several  instances  assumed  great  severity  and 


813  DISEASES   OF  THE   OVAKIES. 

gave  ri^e  to  a  very  great  deal  of  anxiety.  I  found  that  in  most 
cases  this  arose  from  the  carelessness  of  the  nurses,  for  it  was 
almost  impossible  to  get  them  to  understand  what  a  clean 
catheter  really  meant,  and  I  had  to  resort  to  the  expedient  of 
having  the  instrument,  when  not  in  use,  always  kept  in  a  basin 
of  water.  If  this  simple  precaution  was  properly  attended  to, 
my  patients  always  escaped  inflammation  of  their  bladders  ;  but 
even  with  the  most  scrupulous  injunctions,  a  case  of  cystitis 
would  occasionally  occur.  I  therefore  use  the  catheter  now  as 
little  as  possible,  an'd  my  patients  are  always  encouraged  to  pass 
water  for  themselves  as  soon  as  they  can.  Owing,  however,  to 
some  reflex  influence,  arising  doubtless  from  irritation  of  the 
nerves  of  the  pedicle,  they  are  sometimes  quite  unable  to  pass 
water  for  several  days  after  the  operation,  and  then  the  catheter 
must  be  employed  with  the  precautions  I  have  already  indi- 
cated ;  and  if  it  is  to  be  used,  let  me  urge  the  absolute  necessity 
of  these  being  attended  to. 

Another  danger  in  this  matter  is  to  be  avoided — one  which  is 
occasionally  overlooked — over-distention  of  the  bladder.  I  re- 
member being  told  on  two  consecutive  days,  at  each  of  my  vis- 
its, by  one  of  my  most  intelligent  nurses,  that  a  patient  was 
passing  her  water  all  right.  She  was  an  extremely  nervous 
patient,  and  the  complaint  she  made  of  pain  at  first  did  not  at- 
tract my  attention  ;  but  at  last  I  examined  the  bladder,  and 
found  it  completely  distended,  although  the  nurse  had  informed 
me  that  she  had  passed  a  quantity  of  urine  only  a  few  minutes 
before  my  visit.  The  fact  was  that  what  she  had  passed  was 
the  mere  overflow,  and  probably  the  patient's  bladder  had  been 
distended  for  forty-eight  hours.  Thus,  upon  the  slightest  com- 
plaint on  the  part  of  the  patient  in  the  region  of  the  bladder,  a 
careful  examination  should  be  made.  Fortunately  in  the  case  I 
have  alluded  to  no  harm  ensued,  but  every  consultant  knows 
how  frequently  we  are  called  in  to  see  cases  where  the  bladder 
has  been  allowed  to  remain  over-distended  for  many  days  after 
a  labor,  and  too  frequently  this  is  followed  by  terrible  disasters. 

For  the  treatment  of  cystitis  arising  from  the  use  of  a  foul 
catheter,  or  from  over-distention,  I  know  of  nothing  equal  to  the 
injection  into  the  bladder  of  a  tepid  solution  (five  per  cent.)  of 
hyposulphite  of  soda,  and  the  administration  every  eight  hours 
of  a  soluble  pessary  containing  three  or  four  grains  of  extract 
of  belladonna. 

The  after-course  of  a  case  of  ovariotomy  is  subject  to  many 
rude  checks,  which  alter  its  history  very  much  from  the  fortu- 
nate career  supposed  in  the  preceding  pages.  There  are  many 
dangers  in  the  path  of  every  patient  submitted  to  this  operation. 


OVARIOTOMY.  313 

and  there  are  many  indications  of  their  approach,  but  none  so 
trustworthy  as  those  derived  from,  a  close  observation  of  the  pa- 
tient's temperature-curve.  It  should  be  the  invariable  practice 
of  the  surgeon  to  have  temperature  and  pulse  observations  of 
his  patient  made  night  and  morning  for  a  few  days  before  the 
operation,  and  afterward  these  ought  to  be  repeated  every  four 
hours  for  at  least  ten  days.  Nothing  has  been  to  me  more  in- 
structive than  a  comparison  of  a  group  of  such  charts  ;  and  I 
have  repeatedly  seen  grounds  for  a  prognosis  in  a  case  by  the 
comparison  of  its  temperature-range  with  those  of  former  cases. 
It  will  almost  invariably  be  found  that,  immediately  after  the 
operation,  the  temperature  falls  considerably.  I  have  seen  it  do 
so  as  much  as  two  degrees,  indicating  the  risk  the  patient  has 
to  run  in  the  form  of  shock.  To  obviate  this  being  carried  to  a 
dangerous  extent,  it  is  always  well  to  place  hot  water  bottles  to 
the  sides  and  feet,  and,  if  depression  be  severely  marked,  to  ad- 
minister a  diffusible  stimulant.  By  far  the  best  is  an  enema  of 
diluted  champagne,  with  a  little  brandy.  It  is  generally  neces- 
sary to  administer  a  small  dose  of  morphia — one-third  or  one- 
fourth  of  a  grain— immediately  after  the  operation,  by  supposi- 
tory, and  by  this  I  believe  shock  may  be  warded  off  in  great 
measure,  and  the  after-sickness  prevented. 

From  the  twelfth  to  the  twentieth  hour  after  the  operation, 
the  temperature  slowly  rises,  unless  the  patient  succumb  to  the 
shock  ;  or,  in  the  still  rarer  condition,  where  the  operation  has 
had  to  be  undertaken  on  an  emergency  due  to  cyst-inflamma- 
tion or  an  attack  of  peritonitis,  in  which  case  the  temperature 
falls.  In  a  case  of  the  latter,  where  I  operated  with  a  tempera- 
ture of  nearly  40°  Centigrade,  it  fell  in  twenty-four  hours  to  37°. 

After  the  recovery  from  shock,  the  patient  generally  breaks 
out  into  a  gentle  perspiration,  and  this  should  be  slightly  en- 
couraged, and  the  temperature  may  vary  from  36.8°  Centigrade 
to  38.5°  without  giving  rise  to  any  alarm.  If  it  rise,  however, 
above  the  latter  point,  especially  if  accompanied  by  an  in- 
creased pulse  frequency,  dry  tongue,  pain,  and  inflation  of  the 
abdomen,  green  vomiting  or  hiccup,  and  anxious  face,  the  ac- 
cess of  peritonitis,  in  some  form  or  other,  may  be  taken  for 
granted.  The  treatment  of  this  must  vary  very  much  accord- 
ing to  the  circumstances  of  each  case. 

Vomiting  and  distention  used  to  be,  as  I  have  said,  an  inva- 
riable indication  of  an  ultimate  fatal  issue.  In  the  old  days  of 
the  clamp,  when  we  saw  these  symptoms  come  on  accompanied, 
as  they  always  were,  by  the  unmistakable  expression  of  face, 
we  knew  only  too  well  that  our  efforts  had  been  in  vain.  Now 
it  is  extremely  rare  to  see  either  of  these  symptoms  of  an  extent 


314  DISEASES    OF   THE   OVARIES. 

sufficient  to  give  rise  to  much  anxiety.  We  do  see  sickness,  and 
sometimes  it  is  green  and  bilious,  and  we  occasionally  have 
some  little  distention,  but  they  very  rarely  cause  us  any  trouble. 
For  the  treatment  of  the  sickness,  I  find  the  most  effectual  rem- 
edy to  be  a  small  dose  of  sulphate  of  magnesia,  thirty  or  forty 
grains  in  tepid  water,  repeated  every  other  hour  or  every  hour 
until  the  bowels  have  moved,  or  two  and  a  half  grains  of  calo- 
mel given  every  three  or  four  hours  until  a  similar  effect  is 
produced. 

The  distention  is  nearly  always  started  in  the  transverse 
colon,  and  shows  itself  first  at  the  scrobiculis  cordis,  which, 
after  an  ovariotomy,  is  usually  concave.  I  look  at  every  visit 
at  this  point,  and  teach  all  my  nurses  also  to  watch  it  carefully, 
and  as  soon  as  any  distention  is  visible,  a  tube  is  passed  into  the 
rectum  at  intervals  of  two  or  three  hours,  and  left  in  a  short 
time  to  enable  the  flatus  to  escape.  If  either  of  these  symptoms 
advance  to  any  alarming  extent,  I  use  still  more  active  meas- 
ures to  get  the  bowels  moved,  because  I  always  find  that  as 
soon  as  a  motion  has  passed  they  rapidly  disappear. 

If,  at  the  time  of  the  operation,  it  has  been  thought  necessary 
to  follow  the  plan  of  drainage,  as  introduced  by  Koeberle  and 
Keith,  a  little  extra  care  must  be  taken  with  the  case.  I  have 
now  had  considerable  personal  experience  of  this  method,  and 
I  am  quite  satisfied  from  the  cases  in  which  I  have  used  it, 
and  from  what  I  know  of  Dr.  Keith's  work,  that  there  will 
occur  every  now  and  then  a  severe  case  in  which  it  will  be 
found  absolutely  necessary  to  employ  it.  The  tubes  we  use  are 
made  of  ordinary  glass,  formed  somewhat  like  a  test-tube,  with 
an  overhanging  lip  with  which  they  may  be  secured  by  one  of 
the  sutures  against  the  possibility  of  falling  inside.  They  vary 
in  size  and  length,  having  a  diameter  of  from  three-fourths  of 
an  inch  down  to  one-fourth  of  an  inch,  their  length  being  from 
three  to  six  or  seven  inches.  In  some  of  my  operations  upon 
the  liver,  I  have  had  to  use  them  a  good  deal  longer  ;  but  for  an 
ovariotomy  this  length  will  generally  be  found  quite  enough — in 
fact,  it  will  rarely  be  necessary  to  use  them  more  than  four 
inches  long.  For  at  least  half  its  length  the  tube  is  perforated 
with  small  holes  through  which  the  fluid  drains  into  it  from  the 
cavity  of  the  pelvis.  Just  before  closing  the  wound,  the  tube  is 
placed  with  its  bulbous  end  clown  into  the  cavity  of  the  pelvis, 
care  being  taken,  of  course,  that  it  is  placed  l)ehind  the  uterus, 
and  that  it  does  not  interfere  with  a  loop  of  intestine.  Very 
soon  after  the  wound  is  closed,  it  will  be  found  that  the  serum 
drains  from  it,  and  the  amount  of  fluid  which,  in  the  course  of 
a  very  short  time,  will  drain  in  this  is  simply  amazing,  for  Dr. 


OVARIOTOMY.  315 

Keith  has  shown  me  three  huge  bottles  containing  an  aggre- 
gate amount  of  probably  ten  or  twelve  pints  drained  from  one 
patient. 

Now,  whether  it  is  or  is  not  necessary  to  drain  this  large 
quantity  a; way  is  not  yet  a  settled  question,  I  believe  that  a 
tube  placed  in  a  healthy  peritoneum  could  be  made  to  drain 
away  an  indefinite  quantity,  for  there  is  no  doubt  that  the  peri- 
toneum, being  a  huge  lymph-sac,  is  constantly  passing  lymph 
either  through  the  intestines  outward  or  from  the  outer  wall  in 
toward  the  intestines.  The  direction  of  this  lymph-stream  is 
not  known,  nor,  indeed,  do  we  know  anything  about  its  physiol- 
ogy ;  but  the  facts  of  pathology  are  alone  sufficient  to  determine 
its  existence.  My  own  view  about  drainage  is  that  it  will  be 
useful  only  where  some  addition  to  this  lymph-stream  is  made 
greater  than  the  outlet  can  carry  away.  The  fact  that  I  have 
been  so  successful  in  my  own  operations  without  drainage 
makes  me  think  it  probable  that  I  have  unconsciously  substi- 
tuted purgation  for  drainage  ;  for,  on  looking  over  my  records, 
I  find  that  in  very  many  of  the  cases  where  Dr.  Keith  would 
have  drained  I  have  purged.  This  would  make  it  seem  as  if  the 
intestines  were  to  a  large  extent  the  outlets  of  the  drainage 
stream ;  but  it  will  remain  for  some  time  an  open  question  which 
of  the  two  channels,  the  drainage-tube  or  the  intestinal  canal, 
will  prove  the  better  vehicle. 

Dr.  Marion  Sims'  proposal  to  drain  every  case  by  means  of 
a  tube  passed  from  the  abdominal  cavity  into  the  vagina  was 
one  which  did  not  meet  with  any  very  favorable  reception,  and 
I  feel  quite  sure  that  even  in  Dr.  Keith's  hands,  where  drainage 
of  a  reasonable  kind  is  resorted  to,  the  cases  will  become  fewer 
and  fewer ;  but  still  there  can  be  no  doubt  the  drainage  will 
largely  assist  in  relieving  the  strain  upon  that  absorbent  power 
of  the  peritoneum. 

Dr.  Keith,  after  fastening  in  the  tube,  places  over  it  a  wide 
sheet  of  very  fine  rubber-cloth,  through  which  the  end  of  the 
tube  passes,  and  by  the  aperture  in  which  it  is  firmly  grasped  ; 
some  carbolized  sponges  are  then  wrapped  up  in  this  cloth,  and 
in  this  way  a  very  ingenious  absorbent  dressing  is  formed, 
which  prevents  the  fiuid,  as  it  drains  from  the  tube,  soiling  the 
bed-clothes.  Every  hour  or  two  the  nurses  squeeze  the  sponges 
dry,  or  replace  them  by  fresh  ones,  and  this  is  continued  as  long 
as  the  fluid  is  tinged  red,  sometimes  for  nearly  a  week.  I  em- 
ploy a  much  simpler  method.  I  merely  apply  two  or  three  ab- 
sorbent pads  over  the  tube  and  change  them  when  necessary. 

The  convalescence  of  a  patient  from  an  ovariotomy  may  bo 
interrupted  by  any  of  the  very  many  causes  and  accidental 


316  DISEASES   OF  THE   OVAEIES. 

complications  common  to  all  surgical  operations,  but  these  are 
found  to  be  very  greatly  diminished  by  the  increased  care  we 
now  bestow  upon  the  hygienic  arrangements  of  our  hospitals. 
Thus,  formerly  it  was  not  an  unusual  thing  to  see  a  patient  die 
eight  or  ten  days  after  an  operation  from  an  attack  of  pneumo- 
nia, just  the  same  as  sometimes  occurs  in  large  hospitals  after 
amputations  ;  but  in  the  admirable  building  of  the  New  Infir- 
mary at  Edinburgh,  Dr.  Keith  has  already  performed  quite  a 
large  number  of  operations  with  splendid  success  ;  and  but  a 
few  days  ago  he  told  me,  I  think,  that  there  he  had  done  some 
twelve  or  thirteen  consecutive  cases  successfully  without  any  of 
the  Listerian  or  so-called  antiseptic  precautions. 

Once  or  twice,  after  the  removal  of  very  large  tumors  from 
elderly  women,  I  have  seen  a  short,  rapid  cough  set  in,  rapidly 
increasing  in  severity,  and  killing  the  patient  in  about  thirty 
hours.  What  had  occurred  there  was,  I  believe,  perfectly  anal- 
ogous to  the  suffocative  catarrh  of  old  age.  The  expiratory 
muscles,  perhaps  chiefly  the  diaphragm,  from  long  want  of 
use,  had  become  atrophied,  and,  missing  their  point  d'appui  in 
the  tumor,  were  unable  to  carry  on  the  process  of  expectoration 
of  mucus. 

Occasionally  we  have  the  occurrence  of  tetanus  after  ovario- 
tomy, just  as  we  have  it  after  every  other  surgical  operation. 
Only  once  has  it  occurred  in  my  practice,  and  the  patient  recov- 
ered, probably  because  I  did  nothing  at  all  to  her,  but  left  the 
disease  entirely  alone.  It  is  not  a  subject  upon  which  therapeu- 
tical experiments  have  produced  any  satisfactory  results,  and, 
therefore,  I  think  the  less  its  victims  are  interfered  with,  the 
more  likely  they  are  to  get  well. 

Another  nervous  lesion  I  have  seen  occur  twice  after  ovario- 
tomy, and  in  both  cases  it  has  proved  fatal,  and  several  other 
operators  have  told  me  that  they  have  had  a  similar  unfortu- 
nate experience.  I  refer  to  a  paralysis,  or  what  appears  as 
such,  of  the  muscular  coats  of  the  intestine.  The  abdomen  dis- 
tends rapidly  with  gas,  and  when  examined  after  death,  noth- 
ing is  found  but  the  distention.  In  both  of  my  cases  there  was 
nothing  like  peritonitis.  I  tried  many  things  to  relieve  these 
cases,  including  galvanism  and  puncture  of  the  intestines,  but 
without  benefit. 

Great  stress  used  formerly  to  be  laid  in  all  abdominal  opera- 
tions upon  the  necessity  of  keeping  the  bowels  from  moving, 
and  it  was  formerly  my  practice  to  take  pretty  active  measures 
to  prevent  them  acting  for  ten  or  twelve  days.  This  practice  I 
have  now  entirely  given  up  ;  and  should  there  not  arise  any 
need  for  purging  my  patient,  I  let  matters  alone,  desiring  the 


OVARIOTOMY.  317 

nurses  to  give  her  an  enema  of  warm  water  as  soon  as  she  ex- 
presses any  desire  to  have  a  motion,  and  to  repeat  this  every 
three  or  four  hours  until  it  is  effectual. 

I  have  so  far  only  made  casual  allusions  to  cases  of  explora- 
tory incisions  and  incomplete  operations.  It  is  very  difficult,  in- 
deed, to  lay  down  definite  instructions  upon  this  matter  which 
would  be  of  much  assistance  to  the  beginner.  Of  course,  in  a 
mere  exploratory  incision,  made,  let  us  say,  for  the  purpose  of 
ascertaining  whethes  the  tumor  is  malignant  or  not,  no  special 
difficulty  will  be  experienced.  In  my  own  cases  they  really  are 
but  open  tappings  ;  that  is  to  say,  now-a-days,  when  we  know 
there  is  a  quantity  of  ascitic  fluid  marking  the  outline  of  the 
tumor,  instead  of  tapping  with  a  trocar,  I  simply  make  an  in- 
cision with  a  knife,  large  enough  to  admit  my  finger.  I  empty 
the  cavity,  and,  with  my  finger  and  my  eye,  I  can  generally 
satisfy  myself  upon  the  points  where  I  require  information. 
This  sort  of  operation  is  nothing  more  than  a  tapping,  and  has 
no  more  risk,  so  that  I  hardly  class  it  amongst  the  list  of  explor- 
atory incisions.  What  I  mean  by  the  latter  term  is  when  I 
open  the  abdomen  by  an  incision  big  enough,  perhaps,  to  admit 
my  hand  in  order  to  determine  whether  the  particular  tumor 
can  or  cannot  be  removed.  Here  there  are  one  or  two  dangers 
with  which  the  inexperienced  operator  must  be  acquainted,  and 
which  are  not  always  to  be  avoided  even  by  the  most  experi- 
enced. Thus,  in  a  soft  uterine  tumor,  which  may  very  closely 
resemble  an  ovarian  cystoma,  it  may  very  often  happen  that 
the  bladder  is  pulled  with  it  right  up  out  of  the  pelvis,  and  the 
surgeon's  knife  may  go  through  the  bladder  before  he  recog- 
nizes it.  This  has  three  times  happened  to  me,  but  I  have 
always  carefully  stitched  the  viscus  up,  and  no  harm  has  re- 
sulted from  the  accident.  Whenever,  in  an  exploratory  inci- 
sion, the  bladder  is  found  pulled  up  and  spread  over  the  front  of 
the  tumor  for  a  considerable  distance,  the  proceeding  may  at 
once  be  brought  to  a  conclusion,  for  it  may  be  regarded  as  per- 
fectly certain  that  the  tumor  cannot  be  removed.  Another  dan- 
ger is  in  opening  the  capsule  of  a  very  vascular  tumor,  for  it  is 
often  a  matter  of  the  greatest  difficulty  to  arrest  hemorrhage 
from  such  an  incision  ;  and  when  the  tumor  looks  very  vascular, 
and  is  probably  uterine,  let  me  strongly  urge  the  operator,  whose 
experience  is  not  very  large,  to  be  very  cautious  how  he  touches 
it,  unless  he  is  prepared  to  proceed  with  and  complete  its  re- 
moval. It  is  at  this  point  that  the  great  question  arises  ;  how 
to  direct  an  inquirer  upon  this  difficult  path  I  do  not  know,  un- 
less it  be  to  advise  him  that,  before  he  engages  much  in  abdom- 
inal surgery,  he  had  better  see  a  good  deal  of  it  in  the  practice 


318  DISEASES   OF  THE   OVARIES. 

of  some  one  else ;  for  the  success  of  an  operator  is  to  be  marked 
not  only  by  the  number  of  successful  operations  he  has  per- 
formed, but  also  by  the  diminution  of  those  he  has  left  incom- 
plete. When  and  how  to  complete  the  removal  of  a  tumor  in 
which  there  are  grave  difficulties  can  be  learned  only  by  expe- 
rience, and,  as  I  have  elsewhere  said,  in  my  own  earlier  prac- 
tice I  too  often  left  an  operation  unfinished  which  riper  expe- 
rience would  have  enabled  me  to  complete.  Let  me  here  repeat 
once  again  my  advice  that  the  surgeon  should  most  carefully 
consider  what  he  is  about  to  do  before  he  turns  an  exploratory 
incision  into  an  incomplete  operation  ;  but,  after  having  once 
determined  the  tumor  to  be  a  fit  one  for  removal,  let  him  pro- 
ceed as  speedily  and  as  surely  as  he  may,  attending  carefully  to 
the  precautions  I  have  already  laid  down,  and,  once  having  put 
his  hand  to  the  task,  let  me  say  it  will  be  wiser  for  him  not  to 
turn  back,  but  proceed  to  finish  the  work  he  has  undertaken. 

A  most  remarkable  case  was  narrated  in  a  paper  communi- 
cated to  the  Medico-Chirurgical  Society  of  Edinburgh,  in  May, 
1874,  by  Dr.  Mathews  Duncan.  In  this  paper  Dr.  A.  C.  Camp- 
bell, of  Dundee,  described  a  case  of  cystic  tumor  of  the  kidney, 
simulating  ovarian  disease.  The  patient,  aged  forty-nine,  a 
mill-worker,  had  a  tumor  for  about  eighteen  months  in  the  left 
flank,  as  large  as  a  man's  head,  with  fluctuation,  and  with 
symptoms  of  ovarian  disease.  On  exposure  of  the  tumor  and 
insertion  of  the  trocar,  nothing  came,  as  the  contents  were 
like  porridge.  The  tumor  was  therefore  laid  open,  and  two 
pints  of  the  stuff  cleared  out.  Both  ovaries  were  perfectly 
healthy.  It  was  found  that  the  tumor  was  an  altered  kidney  ; 
it  was,  therefore,  removed.  The  patient  made  a  tedious,  but 
complete  recovery.  About  forty  ounces  of  urine  were  passed 
daily. 

As  a  fitting  conclusion  to  this  chapter  I  place  a  list  of  one 
hundred  and  one  consecutive  operations  for  the  removal  of  ova- 
rian and  parovarian  tumors,  performed  without  any  of  the  Lis- 
terian  details,  and  forming,  as  may  be  seen  from  the  dates,  my 
most  recent  experience.  The  table  shows,  what  seems  to  me  the 
best  method  of  recording  cases.  The  letters  "  H  "  and  "  p  "  mean 
that  the  cases  in  the  respective  columns  were  in  hospital  or  in 
private  practice.  "R"  means  recovery,  and  **D"  means  that 
the  patient  died.  Of  the  hundred  and  one  cases  there  were  only 
three  deaths. 


OVAKIOTOMY. 


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CHAPTER  VI. 

EECENT  EXTENSIONS  OF  ABDO]VIINAL  AND  PELVIC  SUEGEEY. 

In  a  former  chapter,  when  speaking  of  the  pathology  of  the 
ovary,  I  had  occasion  to  point  out  that  our  recent  advances  in 
pelvic  and  abdominal  surgery  have  enabled  us  to  obtain  a  great 
deal  of  information  concerning  the  diseases  of  the  ovaries  which 
formerly  were  beyond  our  reach.  It  has  been  very  well  said 
indeed  that  many  of  our  recent  operations,  to  which  I  pro- 
pose here  to  devote  some  space,  are  quite  as  good  as  post-mor- 
tem examinations  for  the  purposes  of  pathology.  I  would  say 
that  they  are  a  good  deal  better,  because  we  have  by  us,  as  part 
of  the  justification  for  the  operation,  a  complete  clinical  history 
with  which  to  compare  the  diseased  appearances,  and  this  we 
never  have  at  post-mortems,. as  far  as  the  ovaries  and  tubes  are 
concerned. 

In  the  chapter  I  have  just  alluded  to,  I  give  details  of  some  of 
the  cases  in  which  I  have  performed  operations  which,  until 
three  or  four  years  ago,  I  regarded  as  quite  unjustifiable,  but 
which  I  now  regard  as  the  legitimate  outcome  of  our  increased 
success  in  the  removal  of  ovarian  tumors.  If  Mr.  Baker  Brown 
had  continued  to  practise  ovariotomy  for  some  years  after  1867, 
he  would  speedily  have  brought  his  mortality  down  from  ten 
per  cent.,  at  which  he  left  it,  to  four  or  five  per  cent.,  at  which 
Dr.  Keith's  mortality  and  my  own  now  stand,  and  we  should 
have  been  fifteen  years  in  advance  of  our  present  position. 
From  18G7,  as  I  have  already  said,  Mr.  Spencer  Wells  exercised 
an  impregnable  influence  on  the  conduct  of  ovariotomy,  owing 
to  the  accident  of  circumstances,  and  with  his  mortality  of  twen- 
ty-five per  cent,  any  real  advance  of  abdominal  surgery  was 
wholly  impossible.  No  one  could  venture  to  submit  a  woman  to 
such  a  fearful  risk  unless  her  life  was  clearly  menaced,  and 
therefore  ovariotomy  was  always  delayed  as  long  as  possible  ; 
X)alliative  tappings  and  other  blunders  were  perpetrated  ;  but 
worse  than  all,  the  diseases  in  the  pelvis  and  abdomen  which 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SUKGEKY.      323 

•were  amenable  to  surgical  treatment,  but  which  did  not  im- 
mediately and  evidently  destroy  life,  were  left  alone,  and  the 
patients  went  unrelieved.  Dr.  Thomas  Keith  ended  this  dark 
period  by  showing  us  how  to  operate  on  the  abdomen  without 
fear  and  with  little  risk,  and  these  recent  advances  in  pelvic  and 
.abdominal  surgery  should,  in  great  measure,  be  placed  to  his 
-credit,  though  I  do  not  know  that  he  has  engaged  in  them  in  his 
own  personal  practice  to  any  large  extent. 

For  my  own  part,  so  fearless  am  I  now  of  abdominal  surgery, 
so  splendid  have  been  my  results  in  fields  of  practice  which,  until 
three  years  ago,  seemed  hopelessly  enclosed,  that  I  venture  to 
lay  down  a  surgical  law,  that  in  every  case  of  disease  in  the  ab- 
domen or  pelvis,  ill  ivhich  the  health  is  destroyed  or  life  threat- 
ened, and  in  ivhich  the  condition  is  not  evidently  due  to  malig- 
nant disease,  an  exploration  of  the  cavity  should  be  made.  I 
have  already  published  a  great  deal  of  work  in  support  of  this 
proposition,  and  some  of  this  I  consider  of  sufficient  importance 
to  reproduce  at  the  close  of  this  chapter. 

In  October,  1871,  Mr.  Hallwright,  of  Summer  Hill,  Birming- 
liam,  asked  me  to  see  with  him  a  woman,  aged  forty-two,  who 
had  suffered  for  years  from  agonizing  pain  in  the  pelvis,  chiefly 
on  the  left  side,  distinctly  referable  to  the  seat  of  the  ovary,  ac- 
companied by  a  variety  of  reflex  symptoms,  of  which  the  most 
marked  was  complete  and  persistent  aphonia.  She  had  for  many 
years  been  under  treatment  at  the  hand  of  Mr.  Hallwright  and 
others,  without  the  slightest  relief.  We  found  the  left  ovary 
large  and  very  tender,  displaced  down  behind  the  uterus,  and 
the  slightest  pressure  upon  it  gave  rise  to  the  characteristic 
sickening  pain.  From  this  pain  she  suffered  on  defecation. 
After  having  seen  the  patient  many  times,  and  after  careful 
thought,  I  ventured  to  suggest  to  my  colleague  that  removal  of 
the  ovary  would  probably  cure  her.  I  recognized  the  gravity  of 
the  proposal,  for  I  had  no  fear  that  her  sufferings  would  kill  her, 
and  she  had  only  some  six  or  eight  years  to  live  before  the  cli- 
macteric period  would  bring  relief  ;  but  both  Mr.  Hallwright 
and  I  thought  it  was  better  that  the  suffering  should  be  saved 
her  for  that  period,  even  at  some  risk  of  life,  than  that  it  should 
be  continued,  making  life  a  burden  to  her  and  to  all  her  sur- 
roundings. The  patient  and  her  friends  arrived  at  quite  the 
same  conclusions  when  the  matter  was  explained  to  them,  and 
the  operation  was  decided  upon.  With  the  assistance  of  Mr. 
Hallwright  and  Mr.  Bennett  May,  I  performed  it  on  February 
11,  1872,  and  found  the  ovary  non-adherent,  as  large  as  a 
pigeon's  egg  and  full  of  thick,  grumous  matter,  which,  at  the 
time,  I  took  to  be  the  fat  of  a  dermoid  cyst.     More  careful  exam- 


324  DISEASES    OF   THE   OVARIES. 

ination  has  since  made  me  believe  that  it  was  a  chronic  abscess, 
for  there  is  a  complete  absence  of  any  skin  structure  in  the  walls, 
and  there  were  no  appearances  of  any  of  the  hair,  teeth,  etc., 
which  characterize  dermoid  tumors.  So  far  as  I  know,  this  is 
the  first  record  in  the  history  of  surgery  of  the  removal  of  a 
small  ovary  on  account  of  pain.  The  patient  made  a  speedy  and 
complete  recovery,  and  has  ever  since  remained  completely  free 
from  pain  in  the  pelvis.  Her  voice  returned,  and  is  now  of  nor- 
mal power.  She  suffers  now  from  some  obscure  disease  which 
has  stiffened  her  knee-joints  and  makes  her  a  cripple,  but  all  the 
symptoms  which  were  in  existence  before  the  ovariotomy  were 
completely  and  permanently  cured  by  it. 

The  success  in  this  case  suggested  to  me  the  possibility  of  re- 
lieving other  conditions  of  a  kind  involving  risk  to  life  by  removal 
of  the  ovaries,  more  particularly  menstrual  hemorrhage  due  to 
uterine  myoma.  Every  one  knows  what  an  intractable  symp- 
tom this  is,  how  rarely  it  yields  to  the  most  energetic  treatment 
of  a  therapeutical  kind,  and  how  many  surgical  expedients  have 
been  devised  for  the  purpose  of  dealing  with  it — enucleation  of 
the  tumor,  hysterectomy,  etc. — all  of  which  have  had  to  be*aban- 
doned  on  account  of  a  mortality  so  high  that  the  operations  be- 
came wholly  unjustifiable.  Dr.  Mathews  Duncan  and  Professor 
Gusserow,  estimate  that  enucleation  has  a  mortality  of  fifty  per 
cent. ,  and  hysterectomy  one  of  seventy  per  cent.  In  my  own 
experience  the  mortality  of  the  former  has  been  much  higher, 
so  that  I  have  given  the  practice  up,  and  have  no  hesitation  in 
denouncing  it  as  unwarrantable  on  account  of  its  risk.  Con- 
cerning enucleation,  there  is  the  additional  objection  that  the 
tumors  grow  again,  at  least  in  the  three  cases  in  which  I  have 
enucleated  successfully,  this  has  been  the  uniform  result.  Di- 
viding the  cervix  has  also  proved  a  wholly  useless  operation, 
for  even  where  it  has  given  relief  it  has  done  so  only  for  a 
very  short  time.  Hypodermic  injections  of  ergotin  and  in- 
jections of  astringents  and  styptics  into  the  uterus  have  also 
proved  useless  and  very  dangerous,  especially  the  latter ;  for  I 
have  had  three  deaths  from  it  in  some  ten  or  eleven  cases.  Yet 
in  these  cases  something  must  be  done,  for  the  hemorrhage 
proves  fatal  in  a  large  number  of  them,  and  even  when  it  does 
not  do  so,  it  utterly  destroys  the  health  and  usefulness  of  the 
lives  of  the  sufferers. 

In  a  recent  discussion  on  this  subject  at  the  International 
Medical  Congress  in  London,  Dr.  Mathews  Duncan  expressed 
the  astonishing  opinion  that  such  cases  did  very  well  if  left  alone, 
and  did  not  demand  any  risky  interference,  yet  he  records  with- 


KECP:NT  extensions  of  ABDOiAIINAL  AND  PELVIC  SURGERY.      325 

out  condemnation  the  high  mortality  I  have  quoted  in  the  cases 
of  enucleation  and  hysterotomy. 

I  remember  very  well  the  first  case  of  death  which  I  witnessed 
from  menstrual  hemorrhage  due  to  a  myoma  occurred  in  Dr. 
Mathews  Duncan's  own  practice,  while  I  was  a  pupil  at  the 
Edinburgh  Infirmary  in  18G2.  The  case  was  impressed  on  my 
memory  because  I  made  a  post-mortem  examination  of  the  pa- 
tient and  carried  the  tumor  to  Dr.  Duncan.  Since  that  time  I 
have  seen  many  deaths  from  this  cause.  But  even  if  only  a 
few  of  the  cases  died,  their  sufferings  are  severe  and  pro- 
tracted, and  they  are  permanent  invalids.  As  an  illustration  of 
this,  I  cannot  do  better  than  quote  a  letter  from  Dr.  Law  Webb 
concerning  a  patient  upon  whom  I  have  recently  performed  a 
successful  operation  of  the  kind  I  am  now  discussing,  on  ac- 
count of  a  tumor  which  grew  after  its  predecessor  had  been  re- 
moved by  enucleation  :  "When  I  first  came  to  this  neighbor- 
hood (Ironbridge,  Salop),  Miss  F.  was  one  of  the  '  confirmed 
invalids '  of  the  place,  and  had  been  in  failing  health  for  some 
years  before  that  date  (1870).  I  must  have  attended  her  at 
short  intervals  for  more  than  nine  years.  She  had  profuse 
hemorrhage  at  every  monthly  period,  and  sometimes  every  fort- 
night for  months  together.  Treatment  did  so  little  good  that 
she  usually  only  sent  for  me  when  the  loss  was  unusually  great, 
or  her  anaemic  condition  alarmed  her  friends.  Her  life  cer- 
tainly has  been  a  misery  to  her  for  the  last  ten  years,  as  she 
has  been  ill  and  laid  by  more  than  half  her  time."  This  graphic 
description  might  be  applied  to  scores  of  cases,  and  if  our  art 
is  to  be  withheld  from  them,  when  we  have  an  absolute  cure 
in  our  hands  for  them,  of  what  use  can  we  claim  to  be  ?  The 
answer  might  very  fairly  be  made  to  Dr.  Duncan  that  there 
must  be  a  pecuniary  inducement  in  keeping  our  patients  in 
chronic  ill  health,  when  they  might  be  promptly  cured.  That 
there  is  a  risk  of  life  attached  to  such  an  operation  is  no  argu- 
ment against  it  ;  at  least  it  would  be  an  argument  equally  strong 
against  every  kind  of  medical  and  surgical  treatment,  and  would 
be  equally  logical  against  railway  travelling.  The  only  effect  of 
the  statement  should  be  to  reduce  that  mortality  as  close  to  a 
vanishing  point  as  may  be,  and  I  am  satisfied  that  can  be  largely 
accomplished. 

I  have  said  that  the  success  with  Mr.  Hallwright's  patient 
induced  me  to  extend  the  principle,  and  on  the  first  of  August, 
1872,  I  removed  both  ovaries  for  the  purpose  of  arresting  men- 
strual hemorrhage,  of  a  perfectly  intractable  character,  in  a  wo- 
man, aged  forty,  who  had  been  for  some  months  under  my  care. 


326  DISEASES   OF   THE   OVARIES. 

The  result  was  a  complete  success,  and  I  heard  of  the  patient 
being  alive  and  well  in  1874.  The  same  idea,  concerning  the  re- 
moval of  small  ovaries,  had  struck  the  minds  of  two  other  sur- 
geons about  the  same  time  as  it  occurred  to  me,  for  up  to  July 
27,  1872,  five  days  before  my  second  case.  Professor  Hegar,  of 
Freiburg,  removed  both  ovaries  for  neuralgia,  with  a  fatal  result ; 
and  on  the  17th  of  August  of  the  same  year,  Dr.  Battey,  of  Rome, 
Ga.,  successfully  operated  upon  a  patient  suffering  from  serious- 
and  complicated  symptoms.  Dr.  Battey  was  the  first  to  publish 
his  cases  and  a  defence  of  his  proceedings  {Atlanta  Medical 
Journal,  September,  1872),  whilst  I  contented  myself  with  dis- 
cussing the  principle  only  in  my  Hastings'  Essay  on  "  Diseases, 
of  the  Ovary  "  (1873). 

For  the  removal  of  small  ovaries,  Dr.  Battey  first  introduced 
the  phrase  "  normal  ovariotomy,"  a  great  mistake,  for  it  was 
at  once  assumed  that  we  proposed  to  remove  healthy  ovaries, 
on  slight  or  insufficient  provocation,  whereas,  with  very  few 
exceptions,  the  organs  are  all  diseased.  This  unfortunate 
phrase  has  been  a  great  stumbling-block,  and  has  excited  an 
amount  of  opposition,  both  professional  and  public,  from  which 
abdominal  surgery,  and  those  who  practise  it,  have  suffered 
not  a  little.  The  terms  " spaying"  and  " castration  of  women  " 
(Hegar)  were  equally  objectionable  for  the  same  reason,  and 
further  from  the  fact  that,  as  far  as  my  practice  is  concerned, 
they  do  not  express  the  facts  of  the  operation.  Dr.  Marion 
Sims  has  attemyjted  to  give  it  the  name  of  ''Battey's  opera- 
tion." but  this  will  not  do  for  very  many  reasons.  Dr.  Sims 
compares  it  with,  and  seeks  the  authority  of  precedent  from 
"Amussat's  operation  "or  "  Syme's  amputation."  But  there 
is  no  parallel  at  all  in  these  cases,  for  in  both  the  proceedings 
are  definite,  and  practically  do  not  vary  ;  whilst  in  the  operation 
I  am  now  discussing,  the  details  vary  indefinitely,  and  so  do  al- 
most equally  the  principles  upon  which  the  operations  are  per- 
formed. For  an  operation  performed  merely  to  "  bring  about 
the  menopause,"  to  quote  Dr.  Battey's  definition  of  his  own  prin- 
ciple, there  must  be  but  a  limited  field,  and  my  own  experience 
of  it  would  be  vague  and  indefinite,  and  my  conclusions  would 
be  doubtful.  Again,  neither  Prof.  Hegar  nor  Dr.  Battey  seems 
to  have  recognized  the  importance  of  the  tubes  in  these  cases^ 
nor  to  have  contemplated  their  removal  for  occlusion  and  dis- 
tention. This  is  an  extension  of  pelvic  surgery  entirely  my 
own. 

Similarly,  I  have  a  strong  objection  to  the  pedantic  inven- 
tion "oophorectomy."  This  properly  describes  the  removal  of 
an  ovarian  cystoma  as  completely  as  it  does  a  '*  Battey's  opera- 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.     327 

tion/'  In  my  own  practice  the  conclusion  is  indicated  that  re- 
moval of  the  Fallopian  tubes  is  more  important  than  removal 
of  the  ovaries,  and  in  by  far  the  larger  number  of  my  cases  that 
alone  might  have  sufficed ;  indeed,  in  many  it  has  done  so. 
Therefore,  if  Greek  inventions  must  be  introduced,  I  should  ask 
for  '•' salpingotomy '' or  "  salpingo-oophorectomy,"  or  '"prosthe- 
kotomy,"'  if  the  pedantry  were  not  ridiculous.  But  I  do  not 
propose  to  attempt  any  reforms  or  additions  to  our  clumsy  no- 
menclature. When  I  remove  an  ovary  I  call  the  operation 
'•  ovariotomy,"  and  by  describing  the  disease  for  which  the  op- 
eration was  done,  I  leave  each  critic  to  class  my  cases  as  seems 
best  to  him.  When  I  remove  diseased  tubes  I  generally,  but  by 
no  means  always,  remove  the  ovaries  with  them,  and  in  these 
cases  I  speak  of  the  operation  as  "  removal  of  the  uterine  ap- 
pendages." 

For  the  purpose  of  classification  I  arrange  the  operations 
which  I  have  performed  upon  the  uterine  appendages  on  account 
of  (a)  pain,  (b)  intractable  hemorrhage,  and  (c)  reflex  symptoms. 
Up  to  the  date  of  writing  they  have  all  been  published  in  detail, 
save  some  of  the  most  recent,  and  it  would  be  quite  impossible, 
within  reasonable  limits,  to  republish  these  details  here.  A  list 
of  cases  was  submitted  to  the  Obstetrical  Section  of  the  Inter- 
national Congress,  with  columns  containing  the  residence  and 
names  of  the  medical  attendants  of  the  patient,  so  that  each 
case  might  be  identified  if  necessary.  The  first  criticism  which 
my  work  met  with  was  that  the  statements  of  it  were  not  true — 
a  criticism  which  no  one  had  the  hardihood  to  make  in  public, 
but  which  was  diligently  circulated  by  some  of  whom  I  ex- 
pected better  things. 

The  next  criticism  was  that  I  was  "  spaying  women — remov- 
ing healthy  ovaries  from  healthy  women" — a  statement  which 
has  been  reiterated  by  many  medical  journals,  including  so  well- 
informed  an  organ  as  the  iance^.  Even  text-books  in  gynaecology, 
such  as  that  of  Hart  and  Barbour,  speak  of  my  "•  excising  the 
ovaries  for  hydrosalpinx  and  pyosalpinx,"  so  that  I  have  become 
almost  tired  of  the  discussion. 

I  hope  it  may  be  for  the  last  time  that  I  give  an  emphatic  de- 
nial to  all  this  sort  of  thoughtless  misrepresentation. 

The  principles  of  this  extension  of  abdominal  surgery  are  few 
and  clear,  and  for  their  establishment  I  think  I  can  give  satis- 
factory arguments. 

The  first  class  of  cases  in  which  we  may  interfere  is  the 
most  doubtful,  and  certainly  the  most  restricted,  and  it  is  that 
to  which  the  term  "Battey's  operation,"  if  it  must  be  used  at 
all,  should  be  confined.    It  is  those  in  which  there  is  no  physical 


328  DISEASES   OF   THE   OVAEIES. 

evidence  of  pelvic  disease,  yet  where  there  are  serious  symptoms 
so  intimately  associated  with  menstruation  as  to  lead  us  to  be- 
lieve that  an  arrest  of  that  function  might  cure  or  relieve  the 
patient  by  the  establishment  of  a  '"  premature  menopause." 

It  must  be  perfectly  evident  that  this  is  such  an  extremely 
vague  field  that  it  may  be  either  very  limited  or  very  much  ex- 
tended. I  have  been  so  very  doubtful  about  it  that  I  have  lim- 
ited it  entirely  to  one  well-pronounced  disease — epilepsy. 

There  is  no  difficulty  in  defining  true  epilepsy,  and  we  find 
that  almost  every  epileptic  woman  is  worse  during  the  men- 
strual week.  In  some  patients  the  fits  are  confined  absolutely 
to  the  menstrual  period,  and  then  we  speak  of  "menstrual 
epilepsy."  I  have  had  very  many  such  cases  sent  to  me  for  the 
purpose  of  having  the  operation  performed,  but  I  have  limited 
the  proceeding  to  five  cases,  all  of  them  being  patients  where 
the  disease  had  resisted  all  other  treatment,  where  the  intellect 
of  the  patients  had  become  affected,  and  their  usefulness  to 
society  completely  impaired,  their  lives  even  being  threatened. 
One  such  case  is  narrated  in  full  in  another  chapter  (p.  107  et 
seq.),  and  others  have  been  published.  All  five  patients  recovered 
and  are  still  alive. 

The  second  case  I  operated  upon  was  a  girl,  aged  eighteen,  who 
had  been  imbecile  from  birth,  and  who  had  developed  the  most 
violent  menstrual  epilepsy  from  the  time  of  the  molimen.  For 
some  months  before  the  operation  she  had  been  so  bad  during 
the  period  as  to  require  the  constant  care  of  two  attendants,  and 
Mr.  Green,  the  superintendent  of  the  asylum  of  which  she  was 
an  inmate,  was  quite  satisfied  that  the  disease  would  shortly 
prove  fatal.  I  operated  on  May  9,  1880,  with  the  result  of  com- 
pletely arresting  menstruation  and  abolishing  the  epilepsy. 
She  is  still  an  inmate  of  the  Birmingham  Borough  Asylum,  and 
is  quite  manageable.  She  gives  slight  indications  of  an  in- 
creased noisiness  and  loquacity  at  the  time  at  which  her  periods 
should  occur,  and  occasionally  at  these  times  she  has  an  attack 
of  petit  mal ;  but  her  violent  epilepsy  has  quite  disappeared,  and 
remains  in  abeyance  now,  more  than  two  years  and  a  half  after 
the  operation. 

In  the  third  case  the  girl  remained  free  from  the  fits  for 
about  six  months,  but  they  are  now  returning  occasionally,  so 
that  I  fear  the  case  will  prove  a  failure,  though  the  operation 
has  completely  arrested  menstruation. 

The  fourth  and  fifth  cases  are  of  too  recent  date  to  express 
any  opinion  about.  In  both  menstruation  is  completely  arrested, 
but  the  fits  have  not  disappeared.  Of  the  fifth,  Dr.  Knipe,  of 
Melbourne,  writes  to  me  that  she  is  very  much  improved  so  far. 


KECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.   329 

It  will  be  seen  from  this,  and  from  the  fact  that  I  have  sus- 
pended for  the  present  further  trial  of  the  operation  in  such 
cases,  that  I  am  not  greatly  in  favor  of  "  Battey's  operation." 
Its  results,  as  far  as  the  recovery  of  the  patients  are  concerned, 
are  satisfactory  enough.  The  removal  of  the  appendages  in 
such  cases  is  the  easiest  operation  possible,  and  ought  never  to 
be  fatal.  Its  secondary  results  are  uncertain,  and  I  am  not  dis- 
posed, in  the  present  aspect  of  professional  opinion,  to  hamper 
my  work  in  other  directions  by  its  discussion  further  at  the 
present  time.  To  operate  in  this  class  of  neurasthenic  cases, 
where  the  symptoms  are  all  subjective  and  the  physical  signs 
negative,  is  a  question  for  further  discussion,  and  for  its  settle- 
ment I  have  absolutely  no  material. 

For  the  arrest  of  intractable  hemorrhage  the  removal  of 
the  uterine  appendages  offers  a  most  satisfactory  field,  as  I  have 
already  shown  (pp.  115  and  153).  The  primary  risks  of  the  op- 
eration are  small,  as  is  shown  in  the  table  on  next  page,  which 
embodies  the  whole  of  my  recent  experience  of  such  cases, 
dating  from  the  time  when  the  advance  of  abdominal  surgery 
made  such  operations  possible.  For  small  tumors,  where  it  is 
an  alternative  to  enucleation,  it  is  far  safer,  and  it  offers  the 
security  against  a  return  of  the  disease  which  enucleation  does 
not.  In  the  case  of  large  tumors  it  is  an  alternative,  in  the 
great  majority  of  instances  to  hysterectomy,  than  which  it  is 
also  much  less  fatal.  In  the  great  majority  of  cases  it  arrests 
the  hemorrhage  and  the  growth  of  the  tumor  at  once,  and  in 
many  the  tumors  shrivel  and  absolutely  disappear.  In  such  as 
do  not  disappear  it  might  form  a  preliminary  step  to  hysterec- 
tomy, though  I  never  made  such  a  use  of  it. 

Hemorrhage  was,  of  course,  the  leading  feature  in  nearly  all  of 
these  cases,  but  in  many  of  them  the  pain  and  discomfort  alone 
would  have  justified  the  operation.  In  the  two  cases  which  were 
fatal  the  anaemia  was  extreme,  and  the  operation  had  not  a  fair 
chance.  In  case  No.  33  the  patient  died  of  cancer  about  five  months 
after  the  operation.  At  the  time  of  the  operation  there  was 
no  appearance  of  the  tumor  being  malignant,  but  by  the  kind- 
ness of  Dr.  Totherick  I  saw  it  after  death,  and  there  was  no 
doubt  of  it  being  cancer.  This  is  the  kind  of  after-history  in 
ovarian  tumors  of  which  I  have  already  spoken  at  length,  and 
doubtless  it  will  be  met  with  in  myoma  when  we  know  more 
about  that  disease.  One  other  case  (23)  has  died  since  the  opera- 
tion, but  I  do  not  know  anything  as  to  the  cause  of  death.  So 
far  as  I  have  been  able  to  learn,  and  that  includes  all  the  rest 
but  two,  the  other  cases  are  alive  and  well,  and  the  secondary 
results  of  the  operation  are  quite  satisfactory. 


330 


DISEASES   OF   THE   OVARIES. 


FORTY-FIVE  CASES  OF   REMOVAL  OF    THE   UTERINE   APPENDAGES   FOR 

MYOMA. 


No. 

Residence. 

Medical  Attendant. 

A.e. 

o^S.       ^-^- 

Hosp. 

P. 

R. 

R. 
R. 

R. 
R. 
R. 
R. 
R. 
R. 
R. 
R. 
R. 

R. 

R. 
R. 
R. 
R. 
R. 
R. 
R. 
R. 
R. 
R. 
R. 

R. 

R. 

R. 

R. 

R. 

R. 

R. 

R. 

R. 

R. 

R. 

R. 

R. 

R. 

R.  { 

R.  1 

R. 

R. 

R. 

R. 

D. 

1 
2 

3 

4 
5 
6 

7 
8 
9 

Leamington 

Cannock  

Walsall 

Southwell 

Leicester 

Chasetown 

Solihull 

Birmingham 

Coventry 

Stourbridge 

Bloxwich 

Bradninch 

Birmingham 

Coventry  

Dr.  Tomkins 

Dr.  Tylecote 

Mr.  John  Clay 

Mr.  Calvert 

Dr.  Clifton 

Dr.  Clarke 

Dr.  Insull 

Dr.  Drummond 

Dr.  Fenton 

47 
52 

34 
52 
42 
39 
46 
49 
47 
50 
35 
42 
44 

32 

41 
43 
35 
43 
47 
38 
43 
40 
51 
37 
40 

86 
40 
37 
46 
45 
49 
45 
40 
44 
33 
21 
46 
45 
44 
35 
35 
44 
45 
32 
35 

W. 
W. 

M. 

S. 

s. 

M. 

S. 
M. 
M. 
S. 
M. 
W. 

s. 

M. 
M. 
M. 

S. 
M. 
M. 

S. 
S. 
M. 
S. 
S. 
M. 

M. 

M. 

S. 

M. 

M. 

S. 

M. 

S. 

M. 

M. 

S. 

S. 

M. 

M. 

M. 

M. 

M. 

M. 

M. 

S. 

1879. 

Oct.  18.. 
Nov.  30  . 

1880. 

Jan.  13  . 
Mar.  10  . 
April  7  . . 
April  22 . 
May  8. . . 
Aug.  17. 
Sept.  1  . 
Sept.  2. , 
Oct.  26.. 
Oct.  16.. 
Dec.  18  . 

1881. 

Jan.  13  . 
Feb.  5  . . 
Feb.  12  . 
April  20. 
June  15  . 
June  17  . 
Aug.  25  . 
Aug.  27 . 
Sept.  19. 
Oct.  4... 
Oct.  30. . 
Dec.  27  . 

188^. 
Jan.  4  . . 
Jan.  4  . . 
Jan.  10  . 
Jan.  29  . 
Mar.  13. 
Mar.  21. 
Mar.  29. 
Mar.  31. 
April  8.  . 
April  11. 
April  20. 
April  27. 
May  6  . . 
June  9   . 
June  12  . 
June  16  . 
June  27  . 
July  13  . 
Sept.  9.. 
Sept.  29 

H. 

H. 
H. 
H. 
H. 

H. 
H. 

H. 
H. 
H. 

H. 
H. 

H. 

H. 
H. 

H. 

H. 
H. 

H. 

H. 

P. 
P. 

P. 
P. 

p! 
p. 

p! 

p". 
p. 
p. 

p. 
p. 

p. 
p. 
p. 
p. 
p. 

p. 
p. 
p. 

p! 

R 

p! 

p. 
p. 

•- 

10 
11 
12 
13 

14 

Dr.  Hammond  Smith . 

Dr.  Somerville 

Dr.  Stephenson 

Dr.  J.  W.  Taylor 

Dr.  Plowman 

Dr.  D'Arcy  Ellis 

Dr.  Kenny 

ix 

15 
16 

Brierly  Hill 

Birmingham 

Darlaston 

17 

Dr.  Sutton 

18 
19 
20 
?,1 

Droitwich 

Birmingham 

Iron  Bridge,  Salop. 

Birmingham 

Wolverhampton  . . . 

Broseley 

Ludlow 

Bloxwich 

Birmingham 

Wolverhampton  . . . 

Gloucester  

Conway 

Llandudno 

Birmingham 

Birmingham 

Wolverhampton  .  . . 

Birmingham 

London  

Dudley 

Oxford 

Alf  reton 

Southampton 

Leicester 

Droitwich 

Chesterfield 

Birmingham 

Birmingham 

Ludlow 

Dr.  Cuthbertson 

Mr.  HaU Wright 

Dr.  Law  Webb 

Dr.  Kenny 

99, 

Dr.  Pope 

23 

Dr.  Bartlam 

34 

Dr   Brooks   

25 

26 

27 

Dr.  SomerviUe 

Mr.  C.  J.  Bracey 

Dr.  Lycett    

D, 

28 

Dr.  Eshelby 

29 
30 

Dr.  Pritchard 

Dr.  Nicol     

31 

Dr.  Gaunt 

33 

Mr.  Fairley 

33 

Dr.  Lycett 

34 
35 
36 

Dr.  J.  W.  Taylor  .... 

Dr.  L.  Atkins 

L.  T 

37 
38 
39 

Mr.  G.  Jones 

Dr.  Fielding 

Dr.  Seaton 

40 

Dr.  Clifton 

41 
42 

Mr.  Spofforth 

Dr.  Hale 

43 

Mr.  Bracey 

44 

45 

Dr.  Thomas 

Dr.  Brookes 

H  means  hospital  case.        P,  private  case.        R,  recovery.        D,  death. 


RECENT  EXTENSION'S  OF  ABDOMINAL  AND  PELVIC  SURGERY.      331 

I  have  already  said  enough  about  hydrosalpinx  and  pyosal- 
pinx  to  render  it  quite  unnecessary  to  discuss  them  further  than 
to  insert  here  a  complete  list  of  all  the  cases  upon  which  I  have 
operated  for  these  diseases.  Both  conditions  are  far  more  com- 
mon than  was  believed  previous  to  my  experience,  yet  they 
have  been  quite  well  known,  and  described  for  at  least  half  a 
century. 

Of  the  forty-four  cases  only  four  have  occurred  in  single 
women,  and  the  leading  feature  in  the  history  of  many  of  the 
cases  was  an  attack  of  gonorrhoea.  In  one  case  I  had  to  operate 
in  the  acute  stage  of  the  disease,  which  had  arisen,  on  the  ad- 
mission of  the  husband,  from  this  cause.  In  many  other  cases 
the  origin  of  the  condition  could  clearly  be  traced  to  an  attack  of 
inflammation  after  a  miscarriage  or  after  a  labor. 

A  very  frequent  feature  in  the  history  of  the  cases  was  found 
to  be  that  they  had  one  child,  and  after  that  were  never  free  from 
pain  till  relieved  by  the  operation. 

The  leading  symptom  is  persistent  pain,  intensified  at  the 
periods,  especially  just  before  their  onset,  and  always  made 
worse  by  intercourse.  In  the  great  majority  of  the  cases  mar- 
ried life  had  to  be  completely  suspended,  and  the  function  was 
always  restored  by  the  operation. 

Metrostaxis,  sometimes  so  severe  as  to  amount  to  hemorrhage, 
is  a  very  frequent  symptom,  though  in  some  of  the  cases  men- 
struation is  scanty. 

Of  course  if  the  disease  is  bilateral  the  patients  are  sterile, 
and  this  is  usually  the  case,  though  in  some  only  one  tube 
has  been  found  to  be  affected,  and  then  that  only  has  been  re- 
moved. 

The  operations  are  generally  very  difficult,  for  it  is  quite  ex- 
ceptional not  to  find  the  tubes  and  ovaries  densely  adherent  to 
the  viscera  and  to  the  pelvic  wall,  and  in  some  of  my  operations 
the  difficulty  in  overcoming  these  adhesions  has  transcended 
anything  I  have  ever  seen  in  the  removal  of  cystic  tumors  of  the 
ovary.  In  some  cases  the  hemorrhage  during  the  operation  has 
been  alarming,  but  it  has  always  been  controlled  by  sponge- 
packing.  In  three  of  the  cases  the  diseased  organs  have  been 
removed  only  at  a  second  attempt;  that  is,  in  my  early  practice 
I  had  not  the  courage  and  necessary  dexterity  to  complete  the 
operation,  the  patients  returned  with  increased  sufferings  and 
submitted  to  a  second  attempt  in  which  I  was  successful.  In 
one  case  I  made  three  attempts  to  remove  the  tubes,  the  third 
being  successful. 

All  the  patients  recovered,  and,  with  two  exceptions,  are  still 
alive  and  well.     One  of  these  died  of  English  cholera,  and  the 


332 


DISEASES   OF   THE   OVARIES. 


other  from  acute  melancholia,  having  been  allowed  to  starve 
herself  to  death,  the  folly  of  her  husband  standing  in  the  way 
of  her  removal  to  an  asylum,  where  she  could  have  been  forcibly 
fed. 


TWENTY-FOUR    CASES    OF    REMOVAL    OF    UTERINE   APPENDAGES    FOR 

HYDROSALPINX. 


No. 

Residence. 

Medical  Attendant. 

Age. 

M. 
orS. 

Date. 

Hosp. 

V 

R. 

1 

1879. 

1  Birmingham 

Mr.  Watkin  Williams. 

28 

M. 

May  23 

•• 

p. 

R. 

1880. 

2  Birmingham 

3  Birmingham 

4  Birmingham 

L.  T 

L.  T 

Dr.  Hoare 

37 
28 
33 

M. 
M. 
M 

Aprils 

Sept.  24 

Oct.  5 

H. 
H. 
H 

•• 

R. 
R. 
R. 

1881. 

5 
6 

7 

8 

9 

10 

11 

Redditch    

Dr.  Dodsworth 

Dr.  Hammond  Smith. 

Dr.  Sharp     

Mr.  Hallwright 

Dr.  T.  Chambers 

L.  T 

Dr.  Watson 

39 
27 
37 
34 
29 
38 
33 
37 
32 
49 

M. 
M. 
M. 
M. 
M. 
M. 
M. 
M. 
M. 
M. 

July  14 

Aug.  19 

Oct.  7 

Oct.  19 

Oct.  24 

Nov.   9 

Nov.  14 

Nov  30 

Dec.  10 

Dec.  16 

H. 
H. 
H. 
H. 
H. 
H. 
H. 
H. 
H. 

R 

Stourbridge 

Walsall 

Birmingham 

London  

Walsall 

Warwick 

p 

R. 
R. 
R. 
R. 
R. 
R 

12  Warwick 

Mr.  Bullock 

R 

18  Walsall 

14  Birmingham 

Dr.   Hubbard 

Mr.  J.  R.  Harmar 

R. 
R, 

1883. 

15  Birmingham 

16  Walsall 

17  Birmingham 

18  Lichfield 

19  Birmingham  .    

20  Birmingham 

21  jRedditch 

22  Coventry    

Mr.  Holbeche 

Mr.  Willmore 

Dr.  Hickinbotham .  . . 

Mr.  Clay   

Dr.  Quirke 

L.  T 

Dr.  Mathews    

Dr.  Fenton 

34 
46 
38 
28 
34 
25 
20 
39 
40 
23 

W. 
M. 
M. 
S. 
M. 
M. 
M. 
M. 
M. 
M. 

Feb.  27 

March  7 

April  11 

May  16    

July  13 

Aug.  17 

Sept.  5 

Sept.  8 

Sept.  27.... 
Oct.  12 

H. 
H. 
H. 
H. 

H. 
H. 

p 

p 
p 
p 

_ 

R. 
R. 
R. 
R. 
R. 
R. 
R. 
R 

23  Birmingham 

Dr.  Sawyer 

R 

24  Wansranui.  N.  Z.  .  . . 

Dr.  Conolly 

TWO  CASES  OF  REMOVAL  OF  OVARY  FOR  ABSCESS. 


No. 

Residence. 

Medical  Attendant. 

Age. 

M. 
orS. 

Date. 

Hosp. 

P. 

R. 

1 

Birmingham 

Wolverhampton 

Mr.  Hallwright 

Dr.  Lycett 

42 
37 

isra. 

M.  Feb.  11.... 

1880. 

M.  June  28 

1 

P. 
P. 

R. 
R. 

E  means  lioBpital  case.        P,  private  case,        H,  recovery. 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.      333 


TWENTY  CASES    OF    REMOVAL    OF  UTERINE  APPENDAGE   FOR    PYOSAL- 

PINX. 


Medical  Attendant. 


Sutton Mr.  Evans. 


Hanley Dr.  C.  H.  Phillips. 

Birmingham L.  T 

Birminujham Dr.  Hoare 


Church  Stretton !  Dr.  McLintock 

Darlaston 'Dr.  Cameron 

Cradley ;Dr.  Standish 

Dudley Mr.  Samuel  Berry 


9   Birmingham Mr. 

10  Birmingham Mr. 

11  London i. . . 

12  Stafford Dr. 

13  Stonehouse Dr. 

14  Wednesbury Mr, 

15  Walsall Dr. 

16  Birmingham Dr. 

17  Walsall Mr. 

18  Manchester Dr. 

19  Budleigh Dr. 

20  [Birmingham Mr. 


Green 

J.  R.  Harraar. 


Day 

Eshelby 

J.  C.  Garman , . 

Holliday 

C.  J.  Bracey. . . 

G.  Sharp 

Lloyd  Roberts. 

Evans  

Briggs 


A        '    M. 
^^^-  orS. 


I  1879. 

26     M.  Oct.  11  . 


37 

28 
33 


37 
40 
29 
31 


28 
35 
27 
28 
37 
49 
31 
38 
28 
32 
28 
27 


1880. 

M.  lAug.  3.., 
M.  Sept.  24  , 
M.  Oct. 


Hosp. 


1881. 
M.  March  6.. 
M.  May  21.. 
M.  June  13.. 
S.   lOct.   21., 


M. 

S. 
M. 
M. 
W. 
M. 
M. 
M. 
S. 
M. 
W. 
M. 


I  1883. 

|Feb.  2. . . 
Feb.  9. . . 
Feb.  22.. 
March  4. . 
March  10 
March  13 
April  12.. 
April  21.. 
April  27. . 
June  28.. 
June  28.. 
Aug.  17.. 


H. 


H. 
H. 

H. 

H. 
H. 

H. 
H. 

H. 


P. 
P. 

p! 


..  R. 
..  R. 
P.  R. 
..  R. 
P.  R. 
..  R. 
..  i  R. 
P.  R, 
..  !  R. 
..  I  R, 
P.  i  R. 
..  i  R. 


The  gratifying  success  which  has  followed  these  efforts  in  ab- 
dominal surgery  has  induced  me  to  venture  into  fields  hitherto 
untrodden,  or  very  sparsely  traversed,  and  in  these  my  success 
has  been  quite  as  great. 

The  following  is  a  list  of  operations  of  various  kinds  w''iich 
have  directly  issued  from  the  great  advance  in  ovariotomy  in 
1878,  all  of  which,  with  one  exception,  have  been  successful  : 

Nephrectomy 1 

ISTephrotomy 8 

Cholecystotomy  for  gallstone 4- 

Hepatotomy  for  hydatids  of  liver 10 

Laparotomy  for  pelvic  abscess 2Q 

Laparotomy  for  abscess  of  spleen 1 

Laparotomy  for  hydatids  of  peritoneum 4 

Laparotomy  for  chronic  peritonitis 8 

Laparotomy  for  acute  peritonitis 2 

Laparotomy  for  removal  of  extra-uterine  pregnancy ...     7 

65 


534  DISEASES   OF   TUE   OVAKIES. 

The  only  fatal  case  was  one  of  extra-uterine  pregnancy  with 
a  living  child.  The  mother  died  of  exhaustion,  but  the  child  ip 
now  about  three  years  old  and  is  thriving. 

By  no  means  the  least  satisfactory  groups  in  the  above  list 
are  those  of  acute  and  chronic  peritonitis.  In  these  cases  abso- 
lute cures  have  been  effected,  in  every  instance,  by  the  simple 
plan  of  opening  the  peritoneal  cavity,  cleaning  it  out,  and  drain- 
ing it  for  a  short  time.  That  they  were  cases  of  an  extreme 
kind  might  be  shown  by  their  details,  but  probably  one  will  suf- 
fice. I  take  the  following  description  of  the  patient's  condition 
from  a  letter  written  to  me  by  Dr.  Justin  McCarthy,  who  sent 
her  to  me :  "  The  condition  in  which  I  found  her  was  one  of  the 
greatest  emaciation ;  seldom  have  I  seen  it  greater,  unless  in  the 
last  stage  of  phthisis.  There  was  an  enlargement  of  the  abdo- 
men of  rapid  growth,  and  she  had  incessant  vomiting  and  diar- 
rhoea.*' I  opened  the  abdomen,  cleansed  it,  and  drained  it  on 
May  18,  1882,  and  I  saw  her  five  months  after,  stout  and  robust, 
■and  able  to  perform  any  kind  of  work. 

In  Mr.  Spencer  Wells'  recently  published  book  is  given  a  list  of 
thirty-nine  cases  of  removal  of  uterine  tumor  with  twenty  deaths. 
This  terrible  mortality  would  be  more  than  enough  to  condemn 
the  operation,  and  up  to  a  short  time  ago,  in  my  own  practice,  the 
results  were  nearly  as  bad,  and  I  did  condemn  it  very  strongly. 
I  found,  however,  from  my  failures,  that  it  was,  as  in  ovari- 
otomy, the  method  of  dealing  with  the  pedicle  which  was  at  fault, 
and  now  that  I  have  altered  and  amended  this,  I  have  obtained 
results  which  seem  to  promise  that  I  shall  do  almost  as  well  in 
the  removal  of  uterine  tumors  as  I  have  done  in  ovariotomy. 

Of  the  twenty  deaths  in  Mr.  Wells'  list,  fifteen  occurred  with 
the  use  of  the  ligature  for  the  treatment  of  the  pedicle,  and  only 
one  with  the  clamp.  My  experience  is  quite  in  harmony  with  this. 
I  found  when  I  used  the  ligature,  however  tightly  it  was  tied,  and 
however  carefully  I  stitched  it  up  like  a  stump,  as  advised  by 
Mr.  Wells,  the  stump  shrank  in  a  few  hours  from  the  escape  of  se- 
rum, the  ligature  loosened,  and  the  patient  died  of  hemorrhage. 
In  only  two  cases  have  I  been  successful  with  the  ligature,  and 
in  both  I  added  the  cautery,  and  did  not  sew  up  the  stump. 
Therefore,  it  need  hardly  be  said  that  my  experience  is  not  in 
favor  of  Mr.  Wells'  recommendations  ;  and  it  seems  to  me  more 
than  curious  to  see  Mr.  Wells  deserting  the  clamp  in  the  very 
field  where  its  use  is  promising  to  be  an  advance,  after  he  had 
used  it  for  twenty  years  in  a  field  where  it  was  a  detriment  and 
a  hinderance  to  all  progress. 

I  do  not  gather  from  his  writings  that  in  the  cases  where 
he  employed  the  clamp,  that  it  was  other  than  the  old  caliper 


RECENT  EXTEIiSlONS  OE  ABDOMINAL  AND  PELVIC  .SUIIGEKY.      335 

form,  the  use  of  which  he  made  familiar.  He  seems  to  have 
used  it  in  six  cases,  of  which  only  four  recovered,  which  is  much 
better  than  his  results  with  the  ligature,  for  with  that  treatment 
of  the  pedicle  he  had  fifteen  deaths  and  only  fourteen  recoveries. 
In  my  own  practice  I  found  that  the  caliper-clamp  was  fatal  be- 
cause it  was  quite  impossible  to  close  the  abdominal  wound  accu- 
rately around  the  flattened  stump,  just  as  in  ovariotomy. 

I  found  that  Koeberle's  plan  was  open  to  objection  because  the 
small  size  of  the  wire  cut  the  pedicle  and  gave  rise  to  secondary 
hemorrhage  (in  two  cases),  and  that  (in  one  case)  the  wire  broke 
some  hours  after  the  operation  and  allowed  fatal  hemorrhage  to 
occur.  I  therefore  devised  the  clamp  which  is  figured  on  page 
285,  and  which  has  proved  completely  successful  in  every  case  to 

which  I  have  applied  it,  as  may  be  seen  from  the  following  list : 

• 

EIGHT  CASES  OF  HYSTERECTOMY  FOR  MYOMA  IN  WHICH  THE  PEDICLE 
WAS  TREATED  BY  TAIT'S  CIRCULAR  WIRE  CLAMP. 


Besidence. 


Glasgow . 


2   Stoke-on-Trent.. 


Ellesmere . . . 
Liverpool. . . 
Nottingham. 
Birmingham 
Cheltenham., 
Derby 


Medical  Attendant. 


Dr.  Bruce. 
Dr.  Craig  . 


Age. 


43 


Mr.  J.  W.  Roe i  32 

Dr.  Graham 32 

Dr.  Beddard j  41 

Dr.  Hickinbotham 45 

Dr.  Gooding !  44 

Mr.  Wright  Baker I  38 


M. 
orS. 

Date. 

Hosp. 

P. 

1S80. 

S. 

Sept.  8  . . . 

1S81. 

P. 

M. 

Nov.  17... 

H. 

M. 

April  23. . . 

P. 

S. 

June  13. .. 

P. 

M. 

Aug.  5 

P. 

M. 

Sept.  8 

H. 

M. 

Sept.  28. . . 

H. 

M. 

Sept.  28. . . 

•• 

P. 

K. 
R. 
R. 


R. 
R. 
R. 
R. 
R. 
R. 


H  means  hospital  case.        P,  private  practice.        E,  recovery. 

In  one  of  these  cases  (4)  the  responsibility  of  performing  the 
operation  had  been  declined  by  Mr.  Spencer  Wells,  and  another 
(7)  came  to  me  from  the  Samaritan  Hospital,  where  she  had  been 
under  the  care  of  Mr.  Knowsley  Thornton. 


Cholecystotomy.  ' 

Dr.  Marion  Sims  attributes  to  Dr.  Handfield  Jones,'  and  I 
think  correctly,  the  merit  of  first  suggesting  that  the  liver  and 

'  Reprinted  from  Vol.  LXIII.  of  the  Medico-Chirurgical  Transactions,  published  by 
the  Royal  Medical  and  Chirurgical  Society  of  London. 

^  Mr.  Whitaker  Hulke  has  pointed  out  that  Dr.  Handfield  Jones'  proposal  was  anti- 
cipated by  Jean  Louis  Petit  (Memoires  de  I'Academie  de  Chirurgie,  Tome  I.,  p.  155). 
How  curious  that  so  valuable  a  suggestion  should  lie  dormant  for  nearly  a  century  and 
a  half ! 


336  DISEASES   OF   THE   OVARIES. 

gall-bladder  should  be  included  within  the  field  of  surgical  prac- 
tice more  fully  than  they  had  been  up  to  that  point,  and  particu- 
larly that  surgical  interference  should  be  made  in  cases  where 
death  is  threatened  from  the  impaction  of  a  gall-stone. 

To  Dr.  Marion  Sims  himself  must  be  given  the  credit  of  hav- 
ing followed  out  this  suggestion  with  his  usual  boldness  and 
ability,  and  he  himself  points  out  that  the  case  in  which  he  did 
it  was  not  successful  only  because  the  operation  was  too  long 
delayed. 

To  my  good  fortune  it  has  fallen  to  be  the  first  to  follow  out 
Dr.  Handfield  Jones'  idea  and  Dr.  Sims'  plan  successfully. 

Elizabeth  M ,  aged  forty,  was  admitted  to  the  hospital  on 

August  18,  1879,  having  been  sent  to  me  by  Dr.  Abraham  CoUes, 
of  Bridgnorth,  on  account  of  an  abdominal  tumor. 

She  had  been  married  eighteen  years,  had»borne  six  children, 
her  menstruation  had  always  been  normal,  and  she  had  enjoyed 
perfectly  good  health  until  the  summer  of  1878.  At  that  time  she 
began  to  suffer  from  severe  spasmodic  pains  in  the  right  side, 
these  being  always  aggravated  by  walking  or  by  lifting  even 
slight  weights.  In  September  she  noticed  a  swelling  at  the  seat 
of  pain,  and  this  slowly  increased.  During  last  winter  her  pain 
became  much  more  intense,  her  appetite  failed,  she  lost  strength 
and  flesh  rapidly,  and  on  admission  she  presented  an  emaciated 
and  almost  cachectic  appearance.  She  also  suffered  at  that  time 
from  incessant  headache  and  sickness,  and  obstinate  constipa- 
tion. The  seat  of  pain  was  over  the  right  kidney,  where  there 
was  a  heart-shaped  tumor,  firm  and  elastic,  in  which  no  fluctua- 
tion could  be  detected,  and  which  was  extremely  tender  to  the 
touch.  On  examination  under  ether,  this  tumor  was  found  to 
be  perfectly  movable  toward  each  side  ;  indeed,  it  could  be 
pushed  completely  across  the  middle  line  to  the  left  side.  All 
round  it  a  note  of  intestinal  resonance  could  be  produced.  When 
pushed  over  to  the  left  side,  its  heart-like  shape  became  very 
apparent,  and  when  it  lay  on  the  left  side  of  the  vertebral 
column,  with  its  apex  directed  downward  and  to  the  left,  its  base 
evidently  retained  a  connection  with  the  right  side. 

A  careful  examination  of  the  urine  gave  only  negative  results, 
though  she  spoke  vaguely  of  its  having  been  occasionally  dark 
in  color,  muddy,  and  deficient  in  quantity. 

At  the  consultation  held  upon  the  case,  a  variety  of  sugges- 
tions were  made  for  diagnosis,  the  chief  of  which  were  cystic 
enlargement  of  a  floating  kidney,  a  tumor  of  the  head  of  the 
pancreas,  and  dropsy  of  the  gall-bladder.  But  no  decided  diag- 
nosis was  attempted,  and  my  proposal  to  open  the  abdomen,  and 
thus  ascertain  the  nature  of  the  tumor,  was  agreed  upon. 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SUKOEKY.      337 

On  August  23d  I  opened  the  abdomen  in  the  middle  line  to 
the  extent  of  four  inches,  the  umbilicus  forming  the  centre  of 
the  incision.  It  then  became  at  once  evident  that  the  tumor 
was  a  distended  gall-bladder.  I  passed  the  needle  of  an  aspira- 
tor into  the  apex,  and  drew  off  a  quantity  of  white,  starchy- 
looking  fluid,  probably  amounting  to  between  twelve  and  fifteen 
ounces,  but  I  cannot  speak  positively  as  to  its  amount,  as  it  was 
unfortunately  thrown  away  by  a  nurse  immediately  after  the 
operation.  I  then  opened  the  gall-bladder  at  the  point  of  punc- 
ture, so  as  to  admit  my  finger,  and  came  at  once  upon  a  large, 
round  gall-stone,  lying  loose  in  the  cavity.  This  I  easily  re- 
moved, and  on  further  search  I  found  another  of  rather  larger 
size,  and  probably  of  pear-shape,  at  the  entrance  of  the  duct, 
impacted  in  it,  and  evidently  the  cause  of  the  dropsical  disten- 
tion of  the  gall-bladder.  The  removal  of  this  stone  was  a  matter 
of  very  great  difficulty  ;  in  fact,  it  took  a  very  much  longer 
time  to  effect  than  all  the  other  steps  of  the  operation  put  to- 
gether. From  the  long,  narrow,  funnel-like  cavity  in  which  it 
was  lodged,  and  from  the  mobility  of  the  bladder,  it  was  very 
difficult  to  seize,  and  when  at  last  I  did  get  hold  of  it,  I  found  it 
adherent  to  the  mucous  surface.  I  had  then  to  consider  the  ex- 
treme likelihood  that  in  removing  this  impacted  stone  I  might 
tear  the  walls  to  which  it  was  attached,  and  thus  certainly  kill 
my  patient.  I  therefore  performed  a  very  careful  and  protracted 
lithotrity,  chipping  little  fragments  off  the  stone  regularly  all 
over  its  exposed  surface  till  I  had  the  satisfaction  of  lifting  out 
its  nucleus.  I  then  passed  a  blade  of  a  fine  pair  of  forceps  on 
each  side  of  it,  and  by  a  gentle  squeeze  broke  up  the  remainder, 
and  was  then  enabled  to  lift  it  all  out.  The  weight  of  the  stone 
removed  entire  is  4.3  grammes,  and  that  of  the  fragments  I  could 
gather  of  the  broken  stone  is  2.9  grammes,  but  of  the  latter  stone 
as  much  again  must  have  been  lost  on  the  sponges  which  were 
packed  into  the  wound  during  the  process  of  crushing,  and  upon 
which  I  had  constantly  to  wipe  my  instruments.  I  washed  the 
cavity  out  repeatedly,  and  took  every  precaution  that  I  could  to 
secure  that  no  fragments  were  left.  I  then  stitched  the  wound 
in  the  gall-bladder  to  the  upper  end  of  the  wound  in  the  abdomi- 
nal walls  by  continuous  sutures,  leaving  the  aperture  into  the 
bladder  quite  open,  and  then  I  closed  the  rest  of  the  abdominal 
opening  in  the  usual  way.  The  operation  was  performed  with 
complete  antiseptic  precautions,  and  the  anaesthetic  employed 
was  ether. 

She  rallied  from  the  operation  completely  in  a  few  hours.  I 
dressed  the  wound  antiseptically  the  same  evening  at  11  p.m., 
and  found  the  dressings  stained  with  healthy  bile.  In  the  fur- 
32 


338  DISEASES   OF   THE   OVARIES. 

ther  progress  of  the  case  there  is  very  little  to  report,  save  that 
the  flow  of  bile  from  the  wound  continued  till  September  3d, 
when  the  dressings  were  discontinued  and  zinc  ointment  was 
used  in  their  place.  The  stitches  were  removed  and  the  wound 
was  completely  healed  on  September  0th,  when  she  began  to 
take  solid  food,  up  to  that  time  her  diet  having  been  restricted 
to  milk  and  beef-tea.  On  the  14th  she  sat  up  for  the  first  time, 
and  on  the  30th  she  went  home  quite  restored  to  health,  free 
from  pain  and  all  her  former  symptoms,  and  having  gained  at 
least  fourteen  pounds  in  weight. 

Looking  back  upon  this  case,  I  do  not  think  that  a  more 
accurate  diagnosis  was  possible,  for  there  was  an  entire  absence 
of  those  symptoms  which  usually  characterize  cases  of  gall- 
stone. After  the  operation  she  told  us  that  one  of  her  neighbors 
had  said  to  her  one  day  that  she  thought  the  patient  was  jaun- 
diced, but  beyond  this  no  history  could  be  got  at  of  any  symp- 
toms pointing  clearly  to  the  true  nature  of  the  case.  The  singu- 
lar mobility  of  the  tumor  was  also  a  most  puzzling  condition. 
Fortunately,  our  advanced  practice  in  abdominal  surgery  makes 
our  limited  powers  of  diagnosis  in  such  a  case  of  less  impor- 
tance, and  I  thoroughly  agree  with  Dr.  Sims  that  we  should  not 
wait  till  the  approach  of  almost  fatal  symptoms  puts  the  diagno- 
sis in  unmistakable  fashion,  but  that  "  we  shall  make  an  early 
exploratory  incision,  ascertain  the  true  nature  of  the  disease,  and 
then  carry  out  the  surgical  treatment  that  the  necessities  of  the 
case  may  demand." 

Since  the  original  publication  of  this  paper  I  have  operated 
three  times  for  gall-stone,  and  these  have  recovered  completely. 

Four  Cases  of  Hepatotomy.' 

I.— On  August  15.  1880,  I  was  asked  by  Dr.  Thelwell  Pike,  of 

Malvern,  to  see  a  lady,  Miss  E.  G ,  aged  thirty-seven,  whose 

illness  had  the  following  history  : 

Between  1870  and  1872  she  broke  down  in  health,  suffered 
from  obscure  symptoms  of  which  she  can  now  give  no  very  clear 
account,  but  which  were  referred,  by  three  practitioners  whom 
she  consulted,  to  the  spine.  In  1872  she  consulted  the  late  Mr. 
Garden,  of  Worcester,  who  diagnosed  some  hepatic  mischief, 
but  gave  no  decided  opinion. 

In  1873  she  had  a  severe  inflammatory  attack,  the  symptoms 
of  which  were  regarded  by  her  medical  attendants  as  being  due  to 
diaphragmatic  pleuritis.     That  illness  continued  for  three  weeks. 


'  Reprinted  from  the  Birmingham  Medical  Review,  October,  1881. 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.      339 

Since  then  she  has  never  been  well,  suffering  from  bilious  at- 
tacks, swollen  legs  and  feet,  dyspepsia,  inability  to  walk,  and 
great  mental  depression.  She  asserts  that  the  right  leg  has  al- 
ways been  more  swollen  than  the  left. 

In  1876  she  and  her  friends  noticed  an  alteration  in  her  size, 
she  had  to  have  her  dress  let  out,  her  breathing  became  inter- 
fered with,  and  an  enlargement  on  the  right  side  became  appa- 
rent. This  increased  slowly  till  1879,  when  it  was  evident  that 
the  whole  of  the  right  chest  and  abdomen  were  enormously  in- 
creased in  size,  but  it  was  not  till  February  of  this  year  that  any 
attempt  at  diagnosis  seems  to  have  been  made,  and  the  opinion 
then  seems  to  have  been  that  the  enlargement  was  due  to  malig- 
nant tumor.  In  July  she  came  under  Dr.  Pike's  care,  and  he  di- 
agnosed it  as  a  case  of  hydatids  of  the  liver,  and  this  diagnosis 
was  confirmed  early  in  August  by  Sir  William  Jenner,  who  ad- 
vised the  use  of  the  aspirator.  Dr.  Pike  and  Mr.  Dawson,  of 
Malvern,  aspirated  the  tumor  on  August  11th,  and  withdrew  a 
few  teaspoonf uls  of  clear  serum,  enough  to  establish  the  correct- 
ness of  the  diagnosis  of  multiple  hydatids,  even  though  they 
could  find  no  scolices  in  it. 

When  I  saw  her  on  the  15th,  I  found  her  in  such  a  condition 
that  it  was  evident  death  from  suffocation  and  exhaustion  was 
imminent  if  relief  could  not  be  given.  She  was  propped  up  in 
bed  to  relieve  her  breathing,  and  was  vomiting  incessantly.  She 
was  extremely  emaciated,  had  a  hay-like  odor  of  her  breath, 
pinched  features,  and  yellow  skin,  and  all  the  symptoms  of  ex- 
treme exhaustion.  The  hepatic  dulness  extended  from  the  third 
rib  down  to  the  umbilicus,  crossing  the  middle  line  to  the  left  all 
the  way  for  about  two  inches,  and  much  more  at  the  lower  mar- 
gin. The  whole  of  the  right  side  was  occupied  by  the  tumor,  no 
air  was  entering  the  right  lung,  the  left  was  greatly  interfered 
with,  and  the  heart  was  pushed  much  over  toward  the  left. 
Below  the  right  ribs  distinct  fluctuation  could  be  obtained  over 
the  tumor. 

Acting  upon  the  principle  which  I  have  already  advocated 
in  previous  communications  to  the  Society,  of  opening  the  abdo- 
men in  all  cases  of  tumors  where  life  was  threatened,  and  of  the 
malignity  of  which  there  was  no  certainty,  I  had  no  hesitation 
in  proposing  abdominal  section  in  this  case. 

Dr.  Pike  at  once  concurred  in  my  proposal,  and  it  was  readily 
accepted  by  the  patient  and  her  friends, 

I  therefore  returned  to  Malvern  the  next  day  (August  16th), 
and  performed  the  following  operation  :  Dr.  Pike  gave  ether, 
and  I  was  assisted  by  Mr.  Dawson  and  Mr,  Raffles  Harmar,  I 
made  an  incision  four  inches  long  and  about  two  inches  to 


340  DISEASES   OF  THE   OVARIES. 

the  right  of  the  middle  line,  beginning  at  the  edge  of  the  ribs,, 
and  inclining  slightly  inward  toward  the  umbilicus.  Having 
carefully  secured  all  the  bleeding  points,  I  opened  the  perito- 
neum, and  found  that  there  was  no  adhesion  of  the  liver  to  the 
wall,  and  that  I  had  exposed  healthy  liver-tissue.  Into  this  I 
passed  a  large-sized  aspirator  needle,  and  evacuated  a  few  tea- 
spoonfuls  of  clear  serum,  as  had  been  done  before.  Removing 
the  needle  I  passed  my  knife  into  its  track,  and  made  an  open- 
ing large  enough  for  my  forefinger.  I  then  found  that  the  layer 
of  liver-tissue  was  from  half  an  inch  to  three-fourths  thick.  I 
then  fixed  a  pair  of  Koeberle's  catch-forceps  on  each  of  the  mar- 
gins of  the  wound  in  the  liver,  and  asked  my  assistant  (Mr. 
Raffles  Harmar)  gently  to  draw  them  up  as  I  enlarged  the  inci- 
sion. This  I  did  to  the  extent  of  about  three  inches,  and  the  mo- 
ment I  freed  my  finger,  myriads  of  transparent  globes  of  all 
sizes,  from  a  pea  to  an  orange,  shot  out,  covered  the  table  and 
floor,  and  were  afterward  picked  off  the  floor  all  over  the 
room.  When  the  tension  was  relieved,  I  dug  them  out  with  a 
large  silver  gravy-spoon,  an  instrument  suggested  to  me  by  Dr. 
Pike,  and  this  process  took  much  more  time  than  the  whole  of 
the  rest  of  the  operation,  and  during  its  performance,  Mr.  Har- 
mar miost  skilfully  prevented  any  cysts  entering  the  peritoneal 
cavity,  by  keeping  the  flaps  of  the  liver  close  against  the  abdom- 
inal wound.  Finally,  I  perceived  that  my  gravy-spoon  was 
causing  some  hemorrhage  from  the  inside  of  the  cavity,  which 
had  no  kind  of  lining  membrane,  and  I  had  to  leave  a  consider- 
able quantity  of  cysts  in  the  cavity.  In  the  cut  surface  of  the 
liver,  two  bleeding  points  gave  me  some  anxiety,  but  I  closed 
them  temporarily  with  Koeberle's  forceps,  and  finally  secured 
them  in  the  stitches.  These  I  applied  by  a  common  short 
needle  and  piece  of  silk  in  the  continuous  method,  fastening  the 
wound  in  the  liver,  through  the  whole  thickness  of  the  tissue  tO' 
the  wound  in  the  abdominal  wall,  so  as  effectually  to  close  the 
peritoneal  cavity  ;  I  then  fastened  in  a  wide  glass  drainage-tube- 
eight  inches  long.  The  quantity  of  hydatid  cysts  evacuated,  is 
estimated  by  Dr.  Pike  to  be  about  two  gallons,  and  I  think  the 
amount  is  not  exaggerated. 

The  patient  rallied  well  from  the  operation,  and  seemed  to 
suffer  nothing  from  shock.  Her  sickness  ceased  immediately 
after  the  operation  and  did  not  return,  and  her  breathing  became 
at  once  relieved,  so  that  she  could  lie  flat  on  her  back,  or  on 
either  side. 

I  saw  her  again  with  Dr.  Pike  on  the  10th.  when  I  found  her 
without  a  bad  symptom,  eating  well,  entirely  free  from  pain,  and 
with  the  hepatic  dulness  contracted  to  almost  normal  limits.     A 


KECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.   341 

large  number  of  cysts  had  come  through  the  tube  daily  with  the 
discharge,  which  was  faintly  tinged  with  bile.  Dr.  Pike  washed 
out  the  cavity  twice  a  day  with  weakly  carbolized  water. 

I  saw  her  again  on  September  2d,  and  found  the  wound  heal- 
thy, that  Dr.  Pike  had  removed  the  stitches,  and  that  the  cavity 
held  only  about  half  a  pint.  Only  one  very  small  cyst  had  come 
away  since  my  previous  visit.  I  found  also  that  she  was  gaining 
flesh  rapidly,  and  eating  well,  her  diet  that  day  having  included 
bacon,  cheese,  and  porter. 

The  daily  details  of  the  case  possess  but  little  interest,  beyond 
the  fact  that  at  the  end  of  the  first  week  a  short  (three-inch) 
wide  glass  tube  replaced  the  long  one,  and  in  a  fortnight  more, 
a  f  rubber  tube  was  inserted  instead  of  the  glass.  Fragments 
of  cysts  continued  to  come  away  for  about  a  month,  and  now 
(October  17th)  there  has  been  hardly  any  discharge  at  all  for  a 
fortnight,  and  nothing  remains  but  a  sinus. 

Dr.  Pike  notes  that  one  day  during  the  syringing  out  of  the 
cavity,  she  had  a  sharp,  sudden  pain  passing  round  from  right 
to  left.  This  lasted  some  three  or  four  hours,  and  after  that 
about  half  a  pint  of  bile  was  passed  from  the  wound,  and  the 
pain  gradually  ceased. 

The  patient  herself  writes  to  me  that  she  feels  now  quite 
well,  and  is  able  to  walk  about  alone,  not  quite  eight  weeks  af- 
ter the  operation.  She  is  now  (1882)  in  perfect  health  and  has 
married. 

II. — J.  D ,  aged  fifty-six,  was  seen  by  me  for  the  first  time 

on  February  5,  1881,  in  consultation  with  Dr.  G.  P.  Hadley,  of 
Lozells,  under  whose  care,  in  conjunction  with  Dr.  Heslop  and  Dr. 
B.  Foster,  he  had  been  for  some  months.  Dr.  Hadley  has  favored 
me  with  the  following  notes  :  He  saw  J.  D.  for  the  first  time  in 
August,  1879,  when  he  had  an  attack  of  severe  illness  which  was 
regarded  as  due  to  the  passage  of  a  gallstone.  In  January,  1880, 
a  large  tumor  was  discovered  occupying  the  whole  of  the  ef)igas- 
trium,  right  hypochondrium,  and  extending  downward  into  the 
right  iliac  region.  The  tumor  had  an  indistinct  fluctuation. 
During  1880  the  patient  became  greatly  emaciated,  passed  gen- 
erally clay-colored  stools,  and  frequently  had  his  urine  deeply 
tinged  with  bile.  In  December,  1880,  the  cyst  seemed  to  find  an 
opening  into  the  intestine,  for  the  tumor  became  greatly  dimin- 
ished in  size,  and  the  patient  passed  large  quantities  of  brick-red 
fluid  from  the  rectum.  After  this  discharge  the  cavity  seemed 
to  refill  in  a  few  days,  and  the  process  was  repeated  at  inter- 
vals. In  January,  1881,  the  process  of  emptying  seemed  to 
cease,  and  it  was  proposed  to  tap  the  cyst,  but  on  account  of 
the  presence  of  intestines  all  over  the  front  of  the  tumor  it  was 


342  DISEASES   OF   THE   OVARIES. 

deemed  more  prudent  to  have  an  exploratory  incision  made,  and 
I  was  asked  by  his  attendants  to  undertake  this.  I  had  no 
hesitation  in  doing  so,  for  I  found  the  patient  extremely  ema- 
ciated, with  a  distinct  icteric  hue,  and  evidently  sinking.  There 
was  a  very  large  cystic  tumor,  apparently  belonging  to  the 
liver,  and  on  February  6th  I  performed  the  following  operation, 
assisted  by  Mr.  Wright  Wilson  and  Dr.  Williams,  of  Dyffrin, 
the  ether  being  administered  by  Mr.  Bennett,  Dr.  Hadley's 
assistant. 

I  made  an  incision  about  three  inches  in  length  over  the 
tumor,  in  the  axis  of  the  right  rectus  muscle,  and  about  three 
inches  to  the  right  of  the  middle  line,  beginning  about  two 
inches  above  the  level  of  the  umbilicus.  The  peritoneum  was 
easily  reached,  but  there  I  found  intestines  and  omentum  glued 
everywhere  over  the  surface  of  the  tumor,  and  I  had  to  exercise 
much  care  in  dissecting  them  off,  so  as  to  clear  a  part  of  the 
cyst  about  two  square  inches  in  area.  There  was,  however,  no 
adhesion  between  the  parietal  layer  of  peritoneum  and  the  sub- 
jacent intestines.  I  then  passed  my  small-sized  trocar  into  the 
tumor,  and  evacuated  seven  and  a  half  pints  of  dark,  bilious- 
colored  fluid.  Wiien  the  cavity  was  emptied  completely,  I  en- 
larged the  opening  made  by  the  trocar  so  as  to  admit  two  fingers, 
and  came  at  once  upon  a  loose  mass,  which  I  removed,  and 
which  proved  to  be  a  slough  of  liver-tissue  weighing  about  one 
ounce.  I  then  stitched  the  edges  of  the  wound  in  the  liver  to 
those  of  the  wound  of  the  abdominal  wall,  and  fixed  in  a  glass 
drainage-tube.  The  cyst  was  clearly  the  liver  itself,  which  had 
been  distended  into  a  shell,  with  apparently  a  pretty  uniform 
thickness  of  about  half  an  inch.  The  fluid  removed  was  care- 
fully examined  by  Dr.  Saundby,  the  Pathologist  to  the  Women's 
Hospital,  and  found  to  consist  of  nearly  pure  bile,  mixed  with 
pus. 

The  progress  of  the  case  must  be  given  briefly,  for  there  is 
very  little  to  tell.  No  effort  was  made  to  conduct  the  treatment 
upon  Mr.  Lister's  principles.  The  glass  drainage-tube  was  left 
in  for  about  a  fortnight,  and  then  a  piece  of  rubber  tube  replaced 
it.  The  temperature  and  pulse  curves  were  almost  normal,  the 
patient's  appetite  rapidly  improved,  and  upon  my  last  visit  to 
him  (March  30th)  there  was  very  little  discharge  from  the 
drainage-tube,  and  he  had  gained  fourteen  pounds  in  weight  in 
the  seven  weeks  which  had  elapsed  since  the  operation.  (P.S. — 
He  has  gained  forty-two  pounds  since  the  operation.  September 
16th.) 

HI. — L.  B ,  aged  twenty-five,  was  placed  under  my  care 

by  Dr.  Thompson,  of   Leamington,   who  had  recognized    the 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.      343 

presence  of  a  large  abdominal  tumor,  which  caused  the  patient 
much  distress.  She  had  been  married  four  years,  but  had  never 
been  pregnant.  Her  illness  began  with  a  sudden  attack  of  pain 
at  the  seat  of  the  swelling,  in  September,  1880,  and  since  then 
the  tumor  had  steadily  grown  till  I  saw  her  in  February.  The 
nature  of  the  tumor  was  doubtful.  It  was  in  the  position  of  the 
right  kidney,  was  movable,  but  had  an  attachment  above,  which 
suggested  an  origin  from  the  liver.  No  distinct  fluctuation 
could  be  discovered  in  it. 

On  February  9th,  assisted  by  Dr.  Thompson  and  Mr.  Raffles 
Harmar,  I  made  an  abdominal  section,  and  found  it  to  be  a 
hydatid  tumor  of  the  liver,  which  had  no  adhesion  to  the  ab- 
dominal wall.  I  opened  the  capsule,  which  consisted  of  a  layer 
of  liver-tissue,  about  a  fourth  of  an  inch  in  thickness,  and 
scooped  out  the  hydatids  with  a  dessert-spoon.  They  were  of 
various  sizes,  from  a  pea  to  a  small  orange,  and  amounted  in  all 
probably  to  a  pint  and  a  half  or  two  pints.  I  was  very  careful 
to  cleanse  out  the  deep  cavity  in  the  liver  very  thoroughly,  and 
Mr.  Harmar  very  skilfully  kept  the  edge  of  the  hepatic  wound 
up  out  of  the  abdomen,  so  that  none  of  the  parasites  escaped  into 
the  peritoneum.  The  wound  in  the  liver  was  stitched  to  the 
wound  in  the  abdominal  wall,  and  a  glass  drainage-tube  was 
fastened  in.  The  after-progress  of  the  case  was  uninterrupted 
recovery,  no  effort  being  made  to  conduct  its  treatment  on  Mr. 
Lister's  principles.  The  glass  tube  was  replaced  by  a  rubber 
tube  at  the  end  of  a  fortnight,  and  she  returned  home  to  Leam- 
ington on  March  9th,  just  a  month  after  the  operation,  and  there 
she  is  rapidly  recovering  under  the  care  of  Dr.  Thompson,  the 
drainage-tube  having  been  removed  (April  23d),  and  the  wound 
is  now  nearly  healed.  (P.S. — This  patient  is  now  in  perfect 
health,  September  16th.) 

IV. — E.  P ,  aged  twenty-one,  and  unmarried,  was  placed 

under  my  care  by  Dr.  Wellesley  Tomkins,  of  Leamington,  in 
August  last,  for  an  abdominal  tumor.  This  I  recognized  at  once 
to  be  an  enlargement  of  the  liver,  and  unhesitatingly  made  a 
diagnosis  of  hydatid  disease.  Her  illness  began  in  April,  1880, 
with  an  attack  of  violent  bilious  sickness,  followed  by  pain  in 
her  back  and  right  side.  The  enlargement  was  noticed  within 
six  weeks,  and  had  steadily  increased.  She  suffered  from  re- 
peated attacks  of  violent  bilious  vomiting.  The  hepatic  dulness 
extended  from  the  fourth  rib  down  to  an  inch  below  the  level  of 
the  umbilicus,  and  from  the  spine  round  to  four  inches  across 
the  middle  line  in  front,  and  distinct  fluctuation  could  be  felt  in 
the  tumor  below  the  ribs.  I  kept  the  case  under  observation 
from  August  till  February,  during  which  period  she  increased 


344  DISEASES   OF   THE   OVARIES. 

two  and  a  half  inches  in  girth  over  the  lower  ribs,  and  fell  off 
markedly  in  health.  I  had  many  consultations  with  profes- 
sional friends  over  the  case,  more  particularly  did  Dr.  Heslop 
give  me  valuable  assistance.  The  question,  of  course,  lay  be- 
tween aspiration  and  hepatotomy,  and  this  could  be  decided 
only  by  our  being  able  to  recognize  which  of  the  two  varieties 
of  hydatid  disease  my  patient  suffered  from. 

No  indication  of  this  could  be  obtained,  and  having  a  lively 
recollection  of  the  disastrous  effect  of  aspiration  in  a  case 
already  published  by  the  Royal  Medico-Chirurgical  Society,  and 
further,  having  a  growing  distrust  in  aspiration  for  abdominal 
surgery,  and  an  increasing  confidence  in  abdominal  section,  I 
determined  upon  the  latter.  I  therefore  proceeded  similarly  as 
was  done  in  the  other  cases.  It  turned  out  to  be  a  large  mono- 
cystic  hydatid.  The  thickness  of  liver-tissue  through  which  I 
passed  was  nearly  an  inch,  and  I  had  a  little  trouble  with 
hemorrhage,  which  was,  however,  completely  controlled  by 
pressure.  I  fixed  in  a  wire  drainage-tube,  after  having  united 
the  edges  of  the  two  wounds,  and  replaced  it  by  a  soft  rubber 
tube  at  the  end  of  a  fortnight.  This  latter  tube  I  finally  re- 
moved on  April  13th,  and  on  the  19th  the  wound  was  almost 
healed,  the  patient  was  getting  about,  eating  wall,  and  rapidly 
gaining  strength.  Possibly,  in  this  case  it  might  have  been 
better  to  have  tried  aspiration  first,  and  that  may  be  the  opinion 
of  some.  I  do  not  agree  with  this,  however,  and  I  see  no  reason 
to  regret  my  action.  I  am  growing  more  and  more  satisfied 
that  all  such  cases  will  be  the  best  treated  by  abdominal  section. 
(P.S. — This  patient,  also,  is  now  in  perfect  health.  I  have 
operated  upon  six  other  cases  of  hydatids  of  the  liver  in  exactly 
the  same  way,  and  all  have  done  well,  September  IG,  1882.) 


The  Treatment  of  Pelvic  Suppuration  by  Abdominal  Sec- 
tion AND  Drainage.' 

I  have  purposely  used  the  words  ''pelvic  suppuration"  in 
the  heading  of  this  paper,  in  order  to  advocate  a  principle  which 
I  believe  to  be  capable  of  a  much  wider  application  than  it  has 
already  had  at  my  hands.  The  cases,  six  in  number,  in  which 
I  have  pursued  this  new  method  of  treatment  have  all  been,  so 
far  as  I  could  discover,  cases  of  suppuration  occurring  in  pelvic 
hsematoceles  ;  but  the  difficulties  in  these  cases  have  been  no 
greater  than  I  think  would  occur  in  pelvic  suppuration  of  almost 

'  Reprinted  from  Vol.  LXIII.  of  the  Medico-Chirurgical  Transactions,  published 
by  the  Royal  Medical  and  Chirurgical  Society  of  London. 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.  345 

any  kind,  and  the  success  has  been  most  exceptionally  encourag- 
ing. My  experience  is,  of  course,  limited  to  suppurations  of  the 
female  pelvis,  but  I  see  no  good  reason  why  the  same  proceed- 
ings should  not  meet  with  equal  success  in  some  cases,  at  least, 
occurring  in  the  male. 

Like  others  who  follow  the  surgical  specialty  in  which  my 
practice  lies,  I  have  had  a  wide  field  for  the  observation  of  the 
various  conditions  classed  under  the  head  of  pelvic  abscess,  and, 
like  others,  I  have  until  recently  confined  my  treatment  of  it  to 
openings  made  from  the  vagina  or  in  the  neighborhood  of  Pou- 
part's  ligament.  Experience,  however,  has  driven  me  to  the 
conclusion  of  Dr.  Emmet,  that  "  I  cannot  regard  the  introduc- 
tion of  the  trocar  into  the  inflamed  tissues  of  the  pelvis  as  a 
procedure  free  from  danger  under  all  circumstances."  It  is  per- 
fectly true  that  in  very  many  cases  where  an  abscess  undoubt- 
edly exists  in  the  cellular  tissue  of  the  female  pelvis,  the  fluid 
can  be  reached  and  removed  by  the  needle  of  the  aspirator. 
But,  according  to  my  experience,  the  relief  obtained  in  this  way 
is,  in  a  large  number  of  cases,  neither  complete  nor  permanent, 
and,  in  nearly  all,  the  convalescence  has  occupied  a  time  not  at 
all  commensurate  with  the  extent  of  the  lesion.  This  is  quite  as 
true  of  abscesses  which  have  been  allowed  to  open  themselves, 
or  have  been  assisted  to  open  in  the  groin.  They  often  continue 
as  fistulous  openings  for  years. 

In  many  cases,  even  when  the  abscess  can  be  reached  by 
vaginal  puncture,  the  nature  of  its  contents  is  such  as  to  make 
its  evacuation  an  impossibility  ;  and  I  have  seen  several  where 
a  puncture  made  at  random  through  an  indurated  pelvic  roof 
has  missed  the  disease.  In  these  cases  the  symptoms  of  the 
presence  of  pus  were  conclusive,  but  no  indication  of  its  seat 
could  be  obtained.  Dr.  Emmet  speaks  of  such  in  these  words  ; 
"  I  can  recall  a  number  of  cases  which  have  been  under  m;y 
observation,  with  thickened  tissues,  where  no  treatment  ha(i 
the  slightest  effect,  and  finally,  they  have  passed  into  other 
hands." 

The  course  of  such  abscesses  is  so  thoroughly  described  by 
Dr.  West  that  his  words  cannot  be  improved  upon,  and  therefore 
I  give  them  at  length  : 

"When  suppuration  takes  place,  the  matter  makes  its  way 
outwardly  through  the  vagina,  or  through  the  intestinal  canal, 
in  almost  all  cases  in  which  the  inflammation  is  limited  to  the 
parts  contained  within  the  broad  ligament.  In  those  cases, 
however,  in  which  the  pelvic  cellular  tissue  is  implicated,  the 
matter  not  unfrequently  makes  its  way  round  between  the  mus- 
cles and  the  external  surface  of  the  peritoneum,  and  the  abscess 


346  DISEASES    OF   THE   OVARIES. 

points  and  discharges  itself  through  the  abdominal  walls  some- 
where in  the  course  of  Poupart's  ligament,  or  a  little  below  that 
situation. 

"  Though  the  size  of  the  abscess  is  not,  in  general,  very 
great,  it  not  unfrequently  passes  into  a  chronic  state,  and 
emptying  itself,  for  the  most  part,  through  some  narrow  passage 
of  communication  into  the  bowel,  the  patient  continues  for 
months  or  years  liable  to  occasional  discharges  of  pus  per  anum, 
the  commencement  of  which  dates  back  to  some  attack  of  in- 
flammation of  the  cellular  tissue  years  before." 

In  an  instance  quoted  by  Dr.  West,  "  occasional  discharges 
of  matter  took  place  from  the  bowel,  and  pus  was  often  inter- 
mixed with  the  faeces,  five  years  after  the  first  symptoms  of  in- 
flammation of  the  cellular  tissue  about  the  uterus,  the  chronic 
results  of  which  were  still  evident  in  a  tumor  which  was  closely 
connected  with  the  rectum  and  the  womb.  These  chronic  ab- 
scesses generally  contract,  and  the  fistulous  passages  that  lead 
to  them  become,  by  degrees,  obliterated,  but  exceptions  to  this 
now  and  then  occur,  two  of  which  have  come  under  my  own 
notice ;  and  Sir  J.  Simpson  has  reported  some  very  interesting 
cases  where  permanent  fistulous  communications  have  formed 
between  the  abscess  succeeding  to  inflammation  of  the  pelvic 
cellular  tissue  and  the  bladder,  uterus,  or  intestinal  canal." 

In  my  own  practice  such  disappointing  cases  have  occurred 
with  but  too  great  frequency,  and  though  I  have  had  some  suc- 
cesses by  the  employment  of  such  means  as  the  elastic  ligature 
{Lancet,  June  27,  1874)  and  counter-opening  in  the  vagina  {Lan- 
cet, April  3,  1875),  yet  the  progress  toward  recovery  has  been  so 
protracted  as  to  contrast  favorably  only  with  those  cases  in 
which  there  was  no  recovery  at  all. 

I  have  been,  therefore,  continually  on  the  outlook  for  some 
means  of  dealing  with  such  cases  which  would  bring  them  as 
satisfactorily  within  our  means  of  treatment  as  are  collections 
of  matter  in  most  other  parts  of  the  body.  This  has  been  fur- 
nished by  the  wide,  free,  and  successful  application  of  abdomi- 
nal section  for  the  treatment  of  pelvic  and  abdominal  tumors, 
and  I  have  now  to  lay  before  the  Society  six  cases,  which  include 
the  whole  of  my  experience  in  this  novel  proceeding,  and  in 
which  success  has  been  obtained  far  surpassing  anything  I  have 
yet  seen  or  heard  of.  In  this  comparison  I  am  of  course  exclud- 
ing those  cases  where  pointing  of  the  abscess  in  the  vagina  is 
evident  at  an  early  stage  of  the  case,  but  even  in  these  the  re- 
covery has  always  been,  in  my  experience,  more  protracted  than 
in  the  six  now  to  be  narrated. 

A  patient  was  sent  to  me  in  February,  1879,  by  Mr.  Gwinnett 


KECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SUKGERY.      347 

Sharp,  of  "Walsall,  suffering  from  a  pelvic  tumor,  associated 
with  very  severe  symptoms.  She  was  twenty-two  years  of  age, 
and  had  been  married  nine  months.  Her  menstruation  had 
always  been  too  frequent  and  too  profuse,  and  six  weeks  before 
I  saw  her  it  had  stopped  suddenly  during  its  course,  and  this 
was  associated  with  the  onset  of  violent  pelvic  pain — one  of  the 
leading  features  of  extra-peritoneal  hsematocele.  A  few  days 
afterward  she  shivered  and  became  very  ill  and  feverish,  and 
these  symptoms  had  become  intensified  when  I  saw  her  ten  days 
after  their  occurrence.  She  was  then  emaciated  and  hectic- 
looking,  with  a  high  night  temperature,  intense  pain  and  ten- 
derness over  the  lower  abdomen,  and  when  examined,  a  large 
fluctuating  tumor,  adherent  to  and  behind  the  uterus,  and  going 
on  either  side  of  it,  was  found  to  occupy  the  pelvis  and  rise  about 
half-way  up  to  the  umbilicus.  The  roof  of  the  pelvis  was  fixed 
and  hard,  and  no  fluctuation  could  be  felt  there. 

The  nature  of  the  tumor  could  be  open  to  only  two  sugges- 
tions :  that  it  was  a  suppurating  parovarian  cyst  with  peritonitis, 
or  a  suppurating  hsematocele.  I  leant  to  the  latter  view,  as  it 
was  in  consonance  with  the  history,  and  I  have  never  known  a 
parovarian  cyst  suppurate,  whilst  hgematoceles  frequently  do. 

In  any  case,  I  determined  to  open  it  from  above,  and  this  I 
did.  I  found  a  large  cavity,  containing  about  two  pints  of  fetid 
pus  with  decomposing  blood-clots.  This  I  carefully  cleansed 
out,  and  after  having  united  the  edges  of  the  opening  into  the 
cyst  carefully  to  the  abdominal  wound,  I  fixed  in  one  of  Koeber- 
le's  glass  drainage-tubes,  five  inches  long.  Seven  days  after  the 
operation  I  placed  a  three-inch  glass  drainage-tube,  and  in  an- 
other week  this  was  replaced  by  a  soft  rubber  tube.  The  patient 
got  up  on  the  twentieth  day  after  the  operation,  and  in  ten 
days  more  went  home  perfectly  well,  with  the  abscess  healed, 
and  she  remains  now  in  perfect  health  (March,  1880). 

The  second  case  was  sent  to  me  by  Dr.  Flynn,  of  Birchills. 
She  was  forty-five  years  of  age,  and  had  never  been  pregnant, 
save  one  doubtful  miscarriage  soon  after  marriage,  nineteen 
years  ago.  Symptoms  resembling  those  of  haematocele  had 
occurred  eight  months  before  I  saw  her,  and  since  that  time  she 
had  been  losing  flesh,  had  lost  her  appetite,  was  troubled  by 
constant  thirst  and  night-sweats,  and  she  had  a  rising  night 
temperature.  The  uterus  was  fixed  in  a  mass  of  effusion  occu- 
pying the  left  broad  ligament,  and  partly  the  right  one  also,  and 
the  mass  on  the  left  side  encircled  the  rectum,  forming  a  pro- 
nounced stricture,  as  hasmatoceles  of  the  left  broad  ligament 
frequently  do.  No  point  of  fiuctuation  could  be  felt  in  the  pel- 
vis, but  the  symptoms  pointed  clearly  to  the  presence  of  pus.     I 


348  DISEASES   OF  THE   OVARIES. 

therefore  determined  to  open  the  abdomen,  and  readily  obtained 
the  consent  of  my  colleague  to  this  proceeding. 

On  reaching  the  peritoneum  the  two  layers  were  found  to  be 
adherent,  so  that  the  cavity  was  not  opened.  A  large  abscess 
was  opened  just  behind  the  base  of  the  bladder,  between  which 
and  the  uterus  it  principally  lay,  but  stretching  round  behind 
the  rectum.  The  floor  and  posterior  wall  of  the  abscess  were 
found  to  consist  of  organized  blood-clot,  so  that  its  origin  was  in 
a  blood  effusion  into  the  broad  ligament.  A  glass  drainage- 
tube  was  inserted,  and  this  was  changed  for  one  of  Chassaig- 
nac's  wire  tubes  on  the  eleventh  day  after  the  operation.  She 
sat  up  on  the  twenty-first  day  after  the  operation,  and  the  tube 
was  finally  removed  on  the  twenty-sixth.  She  went  home  on 
the  thirtieth  day  perfectly  well,  and  has  remained  so  ever  since, 
now  nearly  ten  months. 

The  third  case  was  a  patient  of  Mr.  Hallwright's,  in  whom 
he  had  diagnosed  haematocele  some  four  weeks  before  I  saw 
her.  Symptoms  of  suppuration  set  in,  and  I  performed  exactly 
the  same  operation  as  in  the  first  case,  that  is,  the  peritoneum 
was  opened,  and  the  abscess  emptied  and  cleansed,  and  then 
the  edges  of  its  opening  fastened  to  the  edges  of  the  parie- 
tal wound,  and  a  glass  drainage-tube  fastened  in.  This  case 
also  was  an  undoubted  hsematocele  of  the  broad  ligament.  Eight 
days  after  the  operation  the  glass  tube  was  changed  for  a  wire 
one,  and  this  was  removed  in  twelve  days  more.  She  left  the 
hospital  perfectly  well,  only  thirty-three  days  after  her  admis- 
sion, and  has  since  remained  in  good  health. 

Mary  Ann  B— ,  aged  thirty,  has  been  married  eight  years, 
and  has  had  four  children,  youngest  fifteen  months  old.  Seen 
first  by  Mr.  Hallwright  on  December  12th,  when  she  stated 
that  she  had  become  unexpectedly  unwell  about  five  weeks  ago, 
that  this  was  accompanied  by  violent  pain,  which  has  never 
since  been  absent.  She  was  seen  by  Mr.  Hallwright,  who  diag- 
nosed the  occurrence  of  htematocele  from  the  presence  of  a 
large  hard  tumor  behind  the  uterus.  About  a  fortnight  pre- 
vious to  my  seeing  her  the  nocturnal  exaltation  of  temperature, 
night-sweats,  thirst,  and  increased  pain,  led  Mr.  Hallwright  to 
suspect  that  the  effusion  was  suppurating,  and  when  I  saw 
her  I  had  no  difficulty  in  confirming  his  opinion.  I  therefore 
admitted  her  to  hospital,  and  on  December  22d  I  performed 
abdominal  section,  as  I  found  the  intensity  of  the  symptoms 
increasing,  and  on  examination  under  ether  the  mass  of  the  ef- 
fusion seemed  too  high  up  to  be  opened  safely  from  the  vagina. 
The  tumor  consisted  of  a  large  effusion  of  blood  in  process 
of  disintegration,  contained  in  a  cavity  formed  by  the  lifting 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.      349 

up  of  the  posterior  layer  of  the  broad  ligament,  the  rectum 
being  carried  up  in  front  of  it,  together  with  the  large  ves- 
sels of  both  sides,  as  high  as  the  bifurcation  of  the  aorta, 
whilst  anteriorly  the  peritoneum  dipped  to  a  most  unusual 
depth,  so  that  had  I  tapped  the  tumor  from  the  vagina,  I  must 
have  gone  through  the  peritoneal  cavity.  The  cyst  was  opened 
and  emptied,  and  a  drainage-tube  fastened  in,  and  the  perito- 
neum closed  in  the  usual  way.  Her  recovery  was  neither  so 
easy  nor  so  rapid  as  any  one  of  the  others,  probably  because  the 
cavity  was  the  largest  of  all,  and  her  condition  before  the  opera- 
tion was  very  bad,  though  another  case  to  be  related  was,  in  the 
latter  respect,  much  worse.  The  temperature  in  the  present 
case  was  38.4°  before  the  operation,  and  it  rose  to  40°  on  the 
second  day.  It  did  not  fall  to  37°  till  the  tenth  day,  December 
31st.  The  drainage-tube  was  removed  on  January  10th,  and  on 
the  17th  the  wound  had  perfectly  healed,  and  she  left  the  hos- 
pital on  the  26th.  I  saw  her  on  February  26th,  when  she  was 
hardly  to  be  recognized,  so  astonishing  was  her  restoration  to 
health.  From  a  thin,  emaciated,  and  apparently  dying  woman, 
she  had  been  transformed  into  a  perfect  picture  of  health,  and 
she  stated  that  she  was  able  to  do  her  work  and  get  about  as 
well  as  ever  she  did  in  her  life. 

In  this  case  I  am  quite  satisfied  that  the  delay  of  the  opera- 
tion for  a  few  days  would  have  been  fatal,  and  no  vaginal  tap- 
ping, even  if  it  had  missed  the  peritoneal  layers,  would  have 
emptied  the  cyst  of  its  clotted  contents. 

Ann  S ,  aged  twenty-eight,  placed  under  my  care  in  Jan- 
uary, 1882,  by  Dr.  Gordon,  of  Walsall.  She  is  the  mother  of 
three  children,  the  youngest  being  three  years  of  age.  About 
four  months  ago  she  had  symptoms  resembling  those  of  sud- 
den effusion  of  blood  into  the  broad  ligament.  For  a  month 
she  was  able  to  get  about,  but  during  the  last  three  months  she 
has  been  entirely  confined  to  bed,  the  subject  of  symptoms 
clearly  pointing  to  the  occurrence  of  suppuration.  Dr.  Gordon 
had  discovered  the  presence  of  a  pelvic  mass  behind  the  uterus, 
in  which  no  fluctuation  could  be  discovered,  and  which  was 
fixed. 

I  admitted  her  into  hospital,  and  suspecting  the  case  to  be 
one  of  suppurating  hfematocele,  I  opened  the  abdomen  on  Janu- 
ary oth,  and  found  the  case  to  resemble  the  preceding  one,  save 
that  the  disintegrating  effusion  was  not  so  large.  It  was  dealt 
with  in  the  same  way,  and  the  patient  made  a  much  more  easy 
and  rapid  recovery,  leaving  the  hospital  on  January  17th.  and 
being  restored  to  perfect  health  before  the  end  of  February. 

Mrs.  H ,  aged  twenty-nine,  was  married  at  eighteen,  had 


350  DISEASES   OF   THE   OVAKIES. 

a  child  within  the  year,  and.  has  never  been  pregnant  since.  I 
saw  her,  at  the  request  of  Dr.  Millington,  of  Wolverhampton, 
under  whose  care  she  had  been,  in  conjunction  with  Dr.  Black- 
ford, of  Cannock,  whom  I  met  in  consultation  over  the  case  on 
the  15th  of  January,  1882.  The  history  given  to  me  was  that 
about  nine  weeks  previously,  when  driving  in  an  open  carriage 
with  her  husband  on  a  very  cold  day,  and  during  a  menstrual 
period,  she  was  suddenly  attacked  by  a  violent  pelvic  pain,  and 
coincidently  with  this  the  discharge  ceased.  This  pain  had  con- 
tinued ever  since,  and  had  of  late  increased  in  severity.  Men- 
struation had  occurred  at  two  irregular  intervals  since  the 
beginning  of  her  illness  with  great  profuseness,  and  during 
these  periods  her  pain  nad  been  much  easier.  A  pelvic  tumor 
had  been  discovered  by  Dr.  Millington  some  weeks  before  my 
visit,  and  this  he  had  regarded  as  an  effusion  of  blood.  She  had 
suffered  for  about  three  weeks  before  I  saw  her  from  night- 
sweats,  almost  constant  sickness,  utter  loss  of  appetite,  intense 
thirst,  with  various  other  symptoms  of  pronounced  hectic.  The 
tumor,  when  I  examined  it,  involved  all  the  pelvic  organs  in  a 
fixed  mass  of  cartilaginous  hardness,  with  the  uterus  embedded 
in  it ;  the  bladder  spread  over  it  in  front,  and  the  rectum  en- 
circled by  a  ring  of  hard  effusion.  The  mass  could  be  felt  above 
the  pelvis  as  a  round  and  non-fluctuating  tumor,  with  intestine 
in  front  of  it.  The  patient  had  reached  almost  the  final  stage  of 
exhaustion  and  emaciation.  There  was  no  difficulty  in  diagnos- 
ing the  case  as  one  of  suppurating  hsematocele.  With  Dr. 
Blackford's  concurrence  we  had  her  removed  to  Birmingham, 
and  on  the  21st  I  opened  the  abdomen  and  found  matters  quite 
as  I  had  anticipated.  The  posterior  layer  of  the  broad  ligament 
was  lifted  completely  up  out  of  the  pelvis,  and  so  was  the  an- 
terior layer,  as  far  as  I  could  make  out ;  at  least,  the  only  struct- 
ure I  could  identify  was  the  base  of  the  bladder,  and  that 
seemed  to  form  the  anterior  boundary  of  the  tumor.  From  this 
point  it  spread  backward,  on  a  level  with  the  brim  of  the  true 
pelvis,  and  its  posterior  boundary  was  the  bifurcation  of  the 
aorta.  The  contents  were  clearly  fluid,  and  therefore  I  tapped 
it  with  an  aspirator  needle,  and  evacuated  about  half  a  quart 
bottle  full  of  curdy  blood-colored  pus.  I  then  laid  the  cyst  open 
from  the  point  of  puncture,  in  a  direction  from  before  backward, 
and  found  its  floor  to  consist  of  a  thick  layer  of  laminated  clot, 
hard  and  rigid.  I  could  make  out  the  uterus  rising  out  of  this 
mass,  but  I  could  not  discover  the  rectum. 

I  stitched  the  edge  of  the  opening  into  the  abscess  to  the 
edges  of  the  parietal  wound,  and  then  closed  the  rest  of  the 
peritoneal  opening,  and  fastened  in  a  wide  drainage-tube  of 


RECENT  EXTENSIONS  OF  ABDOMINAL  AND  PELVIC  SURGERY.   351 

glass.  After  the  operation  the  patient's  temperature  never  rose 
above  37°,  she  had  no  more  night-sweats  nor  sickness,  and  her 
appetite  was  really  keen  on  the  third  day.  A  small-sized  wire 
drainage-tube  replaced  the  glass  one  on  the  twelfth  day,  as  the 
discharge  had  become  healthily  purulent  and  free  from  clot 
debris.  The  smaller  drainage-tube  was  removed  on  the  fifteenth 
day  after  the  operation,  and  on  the  twenty-fourth  the  sinus  was 
quite  healed,  she  had  gained  greatly  in  flesh  and  color,  she  was 
able  to  walk  about,  and  on  the  twenty-seventh  day  she  went 
home  perfectly  well,  the  uterus,  however,  being  still  quite  fixed, 
as  I  exi^ect  it  will  remain  for  years.  I  have  just  had  a  letter 
from  her  (March  30th),  in  which  she  reports  herself  as  being  in 
perfect  health. 

In  all  of  these  cases  I  am  satisfied  that  vaginal  tapping 
would  have  been  useless.  In  most  of  the  cases,  if  the  abscess 
had  been  opened  by  natural  processes,  it  would  have  been  into 
the  rectum.  In  the  last  case  it  would  probably  have  been  in  one 
of  the  groins  ;  but  I  think  in  every  one  of  the  cases,  unless  it  be 
in  the  second,  death  would  have  occurred  long  before  a  natural 
outlet  could  have  been  established. 

My  general  conclusion  from  these  cases  is  that  the  opening 
of  such  abscesses  by  abdominal  section  is  neither  a  difficult  nor 
a  dangerous  operation  ;  that  recovery  is  made  in  this  way  more 
certain  and  rapid  than  in  any  other ;  and  that  in  future  I  shall 
always  advise  an  exploratory  incision  where  I  am  satisfied  there 
is  an  abscess  which  cannot  be  reached  nor  emptied  satisfactorily 
from  below. 

Since  the  original  publication  of  this  paper  I  have  operated 
on  fifteen  cases,  and  the  recovery  in  all  the  twenty  has  been 
complete  and  permanent. 


INDEX. 


Abdomen,  law  for  exploration  of,  323 
Abscess  of  ovary,  100,  125,  323 

of    spleen,    successfully    treated, 

pelvic,  treated  by  abdominal  sec- 
tion,  333,  344 
Absence  of  ovaries,  36 
Accessory  or  additional  ovaries,  9 
Acute  ovaritis,  88,  100 
Adhesions,  283 

After-treatment  in  ovariotomy,  307 
Air  in  ovarian  cysts,  194 
Alga3,  reproduction  in,  2 
Anaesthetic,  selection  and  administration 
of,  2(52 
use  of,  for  diagnosis,  195 
Anatomy  of  ovary  and  oviduct,  6 
Animals,  phantom  tumors  in,  205 
Anther,  2 

Antiseptic  system,  so-called,  268 
Aphides,  reproduction  in,  2 
Appendages,  uterine,  removal  of,  for  hem- 
orrhage, 115,  153,  325,  329 
Arteries  of  ovary  helicoid,  28 
Ascites,  diagnosis  of,  168,  197,  218 
Ass,  phantom  tumor  in,  205 
Auscultation  of  ovarian  tumors,  196 
Axial  rotation  of  ovarian  tumors,  295 

Balleray,  Dr.,  on  hernia  of  ovary,  50 
Ballottement,  199 
Bantock,  Dr. ,  on  Listerism,  276 
Battey,  Dr.,  on  "  normal  ovariotomy,"  336 
Bell,  John,  on  ovariotomy,  242 
Bimanual  examination,  193 
Biology,  elementary  instruction  in,  2 
Broad  ligament,  6,  13 
Bronchitis  from  ether,  266 
Brown,  Mr.  Baker,  146,  246 
Bulb  of  ovary,  7 
23 


Cancer,  a  reversion  of  type,  140,  147 

of  peritoneum,  218 
Carbolic  acid  poisoning,  310 
Cartilage  in  tumors,  158 
Castration  of  women,  326 
Catheter,  caution  in  using,  312 
Cautery,  Baker  Brown  on,  246 
Caution  in  use  of  sound,  193,  200 
Chad  wick,  Dr.  J.  R.,  on  rupture  of  Fallo- 
pian tube,  67 
Cholecystotomy  for  gall-stone,  338,  335 
Chronic  ovaritis,  42 
Cirrhosis  of  ovary,  107 
Clamp,  a  retrograde  step,  248,  253 
high  mortality  of,  253 
Tait's  twin,  284 
use  of,  for  uterine  tumors,  316 
Clay,  Charles,  244,  251 
Cleansing  out  peritoneum,  289 
Climacteric  growth  of  omental  fat,  208 
Colica  scortorum,  92 
Contractions  of  uterus,  rhythmic,  211 
Corpus  luteum,  30 
Creighton's  views,  23 
Crib-biting,  206 
Cystic  disease  in  infants,  20 
Cystitis  after  ovariotomy,  313 
Cystoma  and  myoma,  connection  between, 
causing  hemorrhage,  116 

hemorrhagic,  103 

origin  of,  137,  142 

parovarian,  104 

structure  of,  154 
Cysts,  extra  peritoneal,  184 

Dentigenous  cysts,  179 
Dermoid  cysts,   parthenogenetic   develop- 
ment of,  31,  178,  183 
tumors,  175 

contents  of,  175 


354 


INDEX. 


De  Sinety  and  Melassez,  discovery  of,  141 

Diagnosis  of  ovarian  and  parovarian  tu- 
mors, 168 

Discus  proligerus,  29 

Dislocation  of  ovaries,  40 

Doran,  Mr.  Alban,  on  history  of  ligature, 
286 

Drainage  of  peritoneum,  290,  314 

Duncan,  Dr.  Mathews,  on  chronic  ovari- 
tis, 111  ;  on  ovariotomy,  157;  on  my- 
oma, 324 

Dysmenorrhoea,  39 

Education  of  girls,  91 

Enucleation  of  tumors,  157,  288 

Epiblast,  15 

Epilepsy,  menstrual,  107,  328 

Epithelium,  changes  of  intracystic,  143 

ciliated,  144 

cystic,  144 

follicular,  18 
Ergotin,  use  of,  90 
Ether,  how  to  give,  263 
Evolution,  law  of,  26 

of  genital  organs,  11 
Examination  by  vagina,  195 
Exantbematic  atrophy  of  ovaries,  87,  107 

ovaritis,  100 
Excess,  marital,  92 
Exploratory  incision,  253,  317,  323 

preferred  to  tapping, 
202 
Extraperitoneal  cysts,  154 
Extra-uterine  pregnancy,  74,  227 

Fallopian  tube,  anatomy  of,  13,  33 

muscular     hypertrophy 

of,  74 
physiology  of,  33 
potency  of,  71 
pregnancy  in,  74 
relations  of,  6 
rupture  of,  66 

Fibrocystic  tumor  of  uterus,  215 

Fibroma,  158 

Fishes,  ovaries  of,  10 

Fluctuation,  iy(! 

Follicles,  formation  of,  19 

Forceps  left  in  tbe  abdomen,  259 

Fremitus,  hydatid,  190 


Gaertner's  canals,  12 
Galvanic  pessary,  40 
Genu-pectoral  position,  45 
Germinal  epithelium,  15 
Germs  have  no  influence,  271 
Germ  theory,  272 
Graafian  follicles,  21 

H.EMATOSALPINX,  57,  69 
Hemorrhage  from   diseased   ovaries,    115, 
153 
from  uterine  myoma,  324 
Hemorrhagic  cysts,  163 
Henning's  table,  4 
Hepatotomy,  338 
Hermaphroditism,  128 
Hernia  of  ovary,  47 
History  of  ovariotomy,  238 

of  tumors  deceptive,  189 
Hospital  mortality,  27 1 

patients,  differ  from  private  pa- 
tients, 114 
Houston,  Robert,  history  of,  239 
Hunter,  John  and  William,  on  ovariotomy, 

242 
Hydatids  of  liver  successfully  removed,  220 

of  peritoneum,  189,  220 
Hydramnios,  190,  195,  212 
Hydrometra,  213 
Hydroperitoneum,  219 
Hydrosalpinx,  55,  331 

repeated  rupture  of,  113 
Hyperemia  of  ovaries,  88 
Hypererchesis,  55,  103,  130,  177,  180,  182 
Hyperplasia  of  ovaries,  122 
Hypertrophy  of  ovaries,  115 
Hysterectomy,  324,  334 

Ice-cap,  use  of,  unnecessary,  807 
Incomplete  operations,  317 

often  cure,  222,  354 
Infundibulum,  13 
Intermenstrual  pain,  125 
Intracystic  growths,  142 
Iron,  somoiii  mes  dangerous  as  a  remedy,  1 14 

Keith,  Du.  Thomas,  on  Baker  Brown,  246; 

low  mortality  with  cautery,  249-323  ; 
on  drain.age,  249,  200,  315  ;  on  spong- 
ing, 202,  289  ;  on  Listerism,  280 


LNDEX. 


355 


Kidney,  movable,  221^ 

cysts  of,  cured  by  drainage,  224 
successful  removal  of,  234,  318 

KoEBERLJi:,  M.,  167,  249;  his  forceps,  258 

Ligature,  disappearance  of,  288 
long,  Charles  Clay,  246 
short,  Nathan  Smith,  243,  286 
Listerism,  250,  255,  268,  273,  280,  307,  309 
Liver,  hydatids  of,  successfully  removed, 
226,  333,  338 
abscess  of,  333,  338 
Lizars,  John,  243 

MALPiGniAN  bodies,  15 
Marital  excess,  92 
McDowell,  Ephraim,  242 
McMunn,  D. ,  spectroscopic  researches,  168 
Menstruation  apparently  useless,  25 
dependent  on  tubes,  25 
independent    of    ovulation, 

25,  33 
in  ovarian  disease,  190 
Mesentery,  cysts  of,  222 
Mesoblast,  15 
Mesovarium,  27 
Metro-peritoueal  fistula,  200 
Microscopic  research,  methods  of,  155 
Miliary  cancer,  155 
Miner's  enucleation,  157,  288 
Miillerian  duct,  11 

Muscular  elements  of  cyst- walls,  156,  169 
Music,  influence  of,  90 
Myoma,  associated  with  cystoma,  115 

hemorrhage  from,  324 

of  uterus,  216 

cedematous,  217 
Myxoma,  153 

Nephrectomy,  833 
Nephrotomy,  333 
Nerves  of  ovaries,  9 

Obsolescence  of  follicles,  23 

(Edematous  myoma,  217 

Oogonium,  3 

Oophorectomy,  326 

Oospore,  3 

Osteoma,  163 

Ova,  majority  of,  fall  into  peritoneum,  30 


Ovarian  pregnancy,  226 
Ovaries,  abscess  of,  1 00,  125,  323 
absence  of,  36 
accessory,  9 
arteries  of  helicoid,  28 
at  puberty,  25 

calcareous  degeneration  of,  162 
cancer  of,  resembles  foetal  growt^ 

140,  147 
defects  of,  36 
development  of,  15 
dislocation  of,  40 
foetal,  16 

follicular  hypertrophy  of,  115 
hernia  of,  47 
hypereeraia  of,  88 
hyperplasia  of,  115,  123 
of  fishes,  10 
position  of,  5 
posterior  surface  of,  6 
removal  of,  does  not  unsex,  93 
size  and  position  of,  4 
symmetry  of,  4 
tubules  of,  16 
tunica  albuginea,  17 
weight  of,  5 
Ovariotomy,  statistics  of,  319 

preparations  for,  257 
instruments  for,  258 
details  of,  280 
under  difficulties,  291 
during  pregnancy,  293 
peritonitis,  ^94 
origin  of,  238 
normal,  326 
who  is  to  do  it  ?  256 
an  objectionable  word,  184 
not  to  be  done  in  general  hos- 
pitals, 254 
Ovaritis,  most  frequent  on  left  side,  9 
chronic,  42,  94 
acute,  88,  97 
exanthematic,  100 
Ovulation  before  puberty,  25,  29 

after  climacteric,  25,  33 
Ovum,  maturation  of,  34 

dropsical  distention  of,  184 

Pain,  intermenstrual,  125 
Pangenesis,  177 


356 


INDEX. 


Papilloma,  structure  and  origin  of,  154 

nature  of,  two  kinds,  147 
Parovarian  cysts,  104 

removal  of,  not  ovariot- 
omy, 165 
removal  of,   always  suc- 
cessful, 168 
Parovarium,  14 
Parthenogenesis,  21,  178,  180 
Pathogenia  of  cysts,  143 
Pedicle,  treatment  of,  284 

by  cautery,  286 
by  ligature,  285 
Pelvic  abscess,  344 
Peritoneum,  folds  of,  in  pelvis,  6 
hydatids  of,  220 
cleansing  of,  289 
abnormalities  of,  54 
Peritonitis,   cured   by   abdominal  section, 

334 
Personal  experience,  a  factor  in  success, 

272 
Pflliger,  tubes  of,  133,  157 
Phantom  tumor,  204 
Pheasant,  ovarian  tumor  in,  230 
Pollen,  2 

Potash,  salts  of,  90 
Pregnancy,  diagnosis  of,  210 
Fallopian,  74 
ovarian,  226 
spurious,  204 
Priestley,  Dr.,  on  intermenstrual  pain,  125 
Prolonged  operations  very  fatal,  283 
Pseudo-cyesis,  2U4 
Puberty,  accession  of,  87 

ovaries  at,  25 
Pulse  curves,  279 
Pyosalpinx,  57,  01,  331,  333 

Rectum,  examination  by,  194 
Reversions  of  type,  11 
Rokitansky's  tumor,  130,  141,  169 
Rosenmiiller,  organ  of,  12,  107 

Samakitan  Hospital,  misstatements  con- 
cerning, 250 
Sense  of  resistance  as  a  sign,  199 
Signs  of  ovarian  tumor,  192 
Simon's  method  of  rectal  examination,  194 
Sims,  Dr.  Marion,  152 


Sound,  a  dangerous  instrument,  193,  200, 

212 
perforation  of  uterus  by,  200 
Spaying  of  women,  326 
Spectroscopic      examination      of      cystic 

fluids,  168 
Spermatic  artery,  7 

vein,  7 
Spleen,  abscess  of,  333 

enlarged,    mistaken    for    ovarian 

tumor,  225 
Sponges,  extreme  care  required  with,  261 

preparation  of,  263 
Staflfordshire  knot,  286 
Statistics,  319 
Sterility,  21 
Stitches,  291 

Struggle  for  existence,  26 
Suppuration  of  ovarian  tumors,  306 
Symptoms  of  ovarian  tumor,  191 

Tapping  by  vagina,  203 

dangers  of,  202,  220 

of  hydramnios,  disastrous,  213 

ought  to  be  discarded,  169 

Temperature  curves,  279 

Theory  of  cystoma,  author's,  140,  142 

Therapeutics  of  ovarian  tumors,  252 

Thornton,  Mr.  Knowsley,  146,  250 

Toilette  of  the  peritoneum,  263 

Trocar  for  tapping,  203 

for  ovariotomy,  261 

Tubes,  influence  of,  in  menstruation,  26 

Tubo-ovarian  ligament,  14 

Tumor,  gangrenous  or  suppurating,  98 

Tumors  of  ovary : 

adenoid,  136 
axial  rotation  of,  295 
cancer  growing  after  re- 
moval of,  140,  148 
cancerous,  130 
cartilage  in,  158 
classification  of,  133 
colloid,  152 
containing  ova,  139 
dermoid,  175 
diagnosis  of,  188 
fibromatous,  158 
fluid  contents  of,  168 
in  infants,  20,  134 


INDEX. 


357 


Tumors  of  ovary  :  in  old  worarn,  135 

malignant  libroma,  IGO 
myxomatous,  loo 
origin  of,  13o 
osteoma,  163 
Rokitansky's,  1:J9,  169 
structure  of  cystomatous, 

154 
suppuration  of,  306 
unilocular,   never   occur, 
136 

Tympanic  corona,  194 

IjRACnus,  cysts  of,  188 

Uterine  appendages,  removal  of,  66 

myoma,  210 
Uterus,  cystic  tumor  of,  195,  215 
infantile,  37 

perforation  of,  by  sound,  200 
rhythmic  contractions  of,  in  preg- 
nancy, 211 


Vaiucocele,  frequent  in  left  side,  7 
Veins,  ovarian,  peculiarities  of,  9 

Wandering  ova,  growth  into  tumors,  182 

Wells,  Mr.  Spencer,  137,  194,  250;  use  of 
j  clamp,  247,  248  ;  his  high  mortality. 

247,  248,  251,  322,  334;  statements 
concerning  Charles  Clay,  250-252 ;  his 
statistical  method,  251  ;  his  precau- 
tions, 255  ;  on  Listerism,  255,  273. 
276  ;  his  anaesthetic,  262  ;  his  vivisec- 
tions, 291  ;  hysterectomy,  334 

Wiltshire,  ovariotomy   during  peritonitis, 
294. 

Wolffian  body,  11 
duct,  11 

Wounds,  dressing  of,  291 

Zoospore,  2 
Zygospore,  3 


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